Minimally invasive surgical treatment of Robert's uterus with missed miscarriage: case report

Robert's uterus was firstly reported in 1970, it's a rare Müllerian duct anomaly with 2 intra-uterine cavities divided by asymmetrical septum. One of the cavities is completely obstructed to cervix by septum and menstruation fluid retents in this blind cavity, periodical pelvic pain during menstruation can lead attendance to hospital. We report a gravida of Robert's uterus with missed abortion in the blind cavity, who had mild dysmenorrhoea since adolescent age, diagnosed and treated by minimally invasive surgical methods. To our knowledge, it's a previously unreported case which gynaecologists terminated pregnancy in blind cavity of Robert's uterus without resecting the septum while dysmenorrhoea relieved entirely and postoperative volume of menstruation stayed the same as preoperative.

Hystero-embryoscopy: evaluation and evacuation of spontaneous missed abortions

OBJECTIVE

To demonstrate the steps for hystero-embryoscopic evaluation of a 7-week spontaneous missed abortion and evacuation of the products of conception. Illustrate the surgical technique and highlight its advantages in improving the evaluation of spontaneous missed abortions.

DESIGN

Video case presentation and demonstration of surgical technique.

SETTING

Tertiary referral center.

PATIENT(S)

The patient provided consent for the video and its publication.

INTERVENTION(S)

Following vaginoscopy, the cervix was approached without prior blind cervical dilation. Navigation from the endocervix to the endometrial cavity was performed using a 2.9-mm diameter hysteroscope. The endometrial cavity was thoroughly inspected revealing an intact gestational sac and submucosal fibroids. An operative grasper was introduced, the chorion and amnion were penetrated, and embryoscopy was performed. In-flow was reduced for external morphological inspection of the embryo, which was then grasped and retrieved. The procedure was continued by introducing of a 26-french bipolar resectoscope, after which the products of conception were excised without electricity and sent for histologic and genetic analyses.

MAIN OUTCOME MEASURE(S)

This procedure allowed for proper embryonic evaluation and hysteroscopic evacuation of products of conception was successfully performed.

RESULT(S)

Cytogenic analysis of this case revealed a female embryo with trisomy 15. No maternal and fetal cell admixture was noted in the analysis, allowing a precise diagnosis.

CONCLUSION(S)

Hystero-embryoscopy is a valuable diagnostic and therapeutic procedure for cases of missed abortion. It may reveal embryonic morphological abnormalities, expand the diagnostic spectrum in the evaluation of pregnancy loss, and avoid potential complications from blind curettage.

Manual Vacuum Aspiration (MVA) - A safe option for evacuation of first trimester miscarriage in cardiac patients

This case series was done at Armed Forces Institute of Cardiology, National Institute of Heart Disease, Rawalpindi, to observe safety and efficacy of manual vacuum aspiration and frequency of complications in cardiac patients with missed abortion. All cardiac patients presenting in first trimester with diagnosed early foetal demise (missed miscarriage) or incomplete miscarriage were included. Manual vacuum aspiration was done as an outpatient procedure. Cardiac and procedure related complications including arrhythmias, thromboembolism, heart failure and ischaemia were noted. A total of 34 patients were enrolled. Mean age and parity was 25.9±2.25 years and 1.18±1.02. Mitral valve was the dominant valve involved in 20(58.8%) followed by double valve replacement in 5(14.7%), dilated cardiomyopathy 4(11.76%), aortic valve involvement in 3(8.8%) and supra ventricular tachycardia in 2(5.9%) patients. Complete evacuation was achieved in 100% patients and there were no major cardiac or gynaecological complications except arrhythmia in 1(2.9%) patient. MVA seems to be a safe and cost effective intervention compared to other modalities of miscarriage management even in high risk cardiac patients.

Sublingual misoprostol plus laminaria for cervical preparation before surgical management of late first trimester missed abortions, a randomized controlled trial

OBJECTIVE

Comparing the efficacy of low-dose sublingual misoprostol plus laminaria to medium-dose sublingual misoprostol alone for cervical dilation before surgical management of late first trimester missed abortions.

METHODS

Randomized, controlled trial evaluated 70 women with missed abortion, admitted for surgical termination of pregnancy. The patients were randomly assigned to receive 200 μg sublingual misoprostol with cervical laminaria (intervention group) or 400 μg sublingual misoprostol without laminaria (control group), four hours before surgical process. The study is registered at www.irct.ir (IRCT2014070711020N4).

RESULTS

More patients in the intervention group achieved the desired cervical dilation (≥Hegar7) before surgical process than the control group (91.4% versus 17.1%, p < 0.001). Patients in the intervention group experienced less pain during the waiting period (mean Visual Analog Scale scores: 30.8 ± 3.7 versus 43.7 ± 5.9, p < 0.001), and had higher satisfaction level (highly satisfied: 97.1% versus 77.1%, p = 0.02). Four patients in the intervention group and none in the control group had spontaneous expulsion of pregnancy products (p = 0.11).

CONCLUSIONS

Compared to medium-dose sublingual misoprostol alone, using a combination of cervical laminaria plus low-dose sublingual misoprostol before surgical process is associated with significantly more effective and rapid cervical dilation, lower requirement for mechanical dilation, lower abdominal pain and discomfort during the waiting period and higher patients' satisfaction.

Prevalence and risk factors of inadequate cervical dilation following laminaria insertion in second-trimester abortion--case control study

OBJECTIVE

The objective was to explore the prevalence of and risk factors for inadequate cervical dilation following insertion of a single set of laminaria in women scheduled for dilation & evacuation (D&E) at 14-24 weeks' gestation.

STUDY DESIGN

We retrospectively reviewed all cases of women who underwent pregnancy termination by D&E at 14-24 weeks' gestation between January 2003 and December 2013. All cases in which the surgical procedure was cancelled due to failure to achieve adequate cervical dilation after a single set of laminaria inadequate cervical dilation were included. The control group was women who underwent D&E following adequate cervical dilation after a single set of laminaria, and were matched according to gestational week in a ratio of 1:3.

RESULTS

The overall dilation failure rate was 3.2%, with 4.0% among the induced-abortion patients and 1.5% among the patients with fetal demise (p=.002). Patients who had inadequate cervical dilation had lower rates of gravidity (p=.002) and previous spontaneous vaginal delivery (p<.001), along with higher rates of primigravidity, nulliparity (p<.001), previous cesarean section/s (p=.041), previous abdominal surgeries (p=.001) and previous cervical procedures (p=.003), compared to controls. A multivariable logistic regression analysis revealed two risk factors for inadequate cervical dilation following laminaria insertion, namely, previous cesarean section (p=.002) and previous cervical procedure (p<.001), whereas increased gravidity was found to protect against inadequate cervical dilation (p=.002).

CONCLUSIONS

Previous cesarean section/s, cervical procedures and primigravidity were found to be risk factors for failure to achieve adequate cervical dilation after a single set of laminaria. Women who are scheduled for D&E, and in whom one of these risk factors exists, might benefit from additional interventions to achieve better cervical preparation.

Pyomyoma after dilatation and curettage for missed abortion

Infection of a leiomyoma is a very rare clinical entity called pyomyoma. Pathology may be encountered during the reproductive period, pregnancy, and even postmenopausal period. In this report, we present a case of pyomyoma which developed after dilatation and curettage managed by broad spectrum antibiotics and myomectomy to preserve the fertility in a 31-year-old patient.

Retained fetal bones two years after midtrimester dilation and evacuation: a case report

BACKGROUND

Retained fetal parts is an uncommon but recognized complication of pregnancy termination. A case of retained fetal bones, 2 years after midtrimester dilation and evacuation (D&E), is described and utilized as a nidus for literature search and discussion of clinical presentation variations.

CASE

A 27-year-old woman, G2, P1, A1, presented complaining of a 2-year history of vaginal discharge. After visiting several healthcare providers and receiving ultrasound evaluations followed by courses of antibiotics and oral contraceptives, the patient's symptoms persisted. Subsequent hysteroscopy revealed fragments of immature bone. Symptoms resolved after hysteroscopic removal of the bone fragments.

CONCLUSION

Retained fetal parts can present with a variety of clinical symptoms and signs, including chronic pelvic pain, vaginal discharge, and secondary infertility. When symptoms are nonspecific, the condition can mimic other gynecologic conditions. Multiple case reports have described postabortal removal of retained fetal bone at varying time intervals from the antecedent D&E, ranging from days to years. The symptomatic presentation can be temporally remote from the antecedent abortion, and symptoms can mimic other common gynecologic conditions. The entity presents the gynecologist with diagnostic and therapeutic challenges.

Early pregnancy failure: factors affecting successful medical treatment

BACKGROUND

The results of medical treatment for early pregnancy failure are conflicting.

OBJECTIVES

To determine whether gestational sac volume measurement as well as other variables can predict the success rate of medical treatment for early pregnancy failure.

METHODS

The study group comprised 81 women diagnosed with missed abortion or anembryonic pregnancy who consented to medical treatment. Demographic data were collected and beta-human chorionic gonadotropin level was documented. Crown-rump length and the sac volume were measured using transvaginal ultrasound. TVU was performed 12-24 hours after intravaginal administration of 800 micro g misoprostol. If the thickness of the uterine cavity was less than 30 mm, the women were discharged. If the sac was still intact or the thickness of the uterine cavity exceeded 30 mm, they were offered an additional dosage of intravaginal misoprostol or surgical uterine evacuation.

RESULTS

Medical treatment successfully terminated 32 pregnancies (39.5%), 30 after one dose of misoprostol and 2 after two doses (group A); 49 underwent surgical evacuation (group B), 47 following one dose of misoprostol and 2 following two doses. There were no significant differences between the groups in age and gestational week. Gestational sac volume did not differ between groups A and B (10.03 and 11.98 ml respectively, P = 0.283). Parity (0.87 and 1.43, P = 0.015), previous pregnancies (2.38 and 2.88, P = 0.037), and betahCG concentration (6961 and 28,748 mlU, P = 0.013) differed significantly between the groups.

CONCLUSIONS

Gestational sac volume is not a predictor of successful medical treatment for early pregnancy failure. Previous pregnancies and deliveries and higher betahCG concentration negatively affect the success rate of medical treatment.

Expectant management of spontaneous first-trimester miscarriage: prospective validation of the '2-week rule'

OBJECTIVES

To assess uptake and success of expectant management of first-trimester miscarriage for a finite 14-day period, in order to evaluate our '2-week rule' of management.

METHODS

This was a prospective observational study evaluating our proposed 2-week rule of expectant management, which is based on the finding that women managed expectantly are most likely to miscarry in the first 14 days and that to wait longer than 2 weeks without intervention does not confer a greater chance of successful resolution. Eligible women diagnosed with first-trimester miscarriage were offered a choice of expectant management or surgical evacuation under general anesthesia. Inclusion criteria for expectant management were: diagnosis of incomplete miscarriage (heterogeneous tissue, with or without a gestational sac, seen on ultrasound in the uterine cavity and distorting the endometrial midline echo), missed miscarriage (crown-rump length (CRL) >or= 6 mm with absent fetal heart activity) or empty sac (anembryonic pregnancy) based on transvaginal ultrasonography. Women with complete miscarriage, missed miscarriage at the nuchal translucency scan, molar pregnancy or miscarriage >or= 3 weeks in duration (missed miscarriage in which the CRL was >or= 3 weeks smaller than the gestational age based on last menstrual period), or with signs of infection or hemodynamic instability were excluded. Expectant management consisted of weekly ultrasonography for 2 weeks. If after 2 weeks resolution was not complete, surgery was advised.

RESULTS

1062 consecutive pregnant women underwent transvaginal ultrasound examination. Of these, 38.6% (410/1062) were diagnosed with miscarriage, of whom 241 (59%) were symptomatic at the time of presentation and 282 were eligible for the study. These were offered expectant management and 80% (227/282) took up this option. 11% (24/227) were lost to follow-up; therefore, complete data were available on 203 women. Overall spontaneous resolution of miscarriage at 2 weeks was observed in 61% (124/203) of women. Rates of spontaneous resolution at 2 weeks according to the type of miscarriage were 71% for incomplete miscarriage, 53% for empty sac and 35% for missed miscarriage. The incidence of unplanned emergency dilatation and curettage due to gynecological infection or hemorrhage was 2.5% (5/203).

CONCLUSIONS

Expectant management based on the 2-week rule is a viable and safe option for women with first-trimester miscarriage. Women with an incomplete miscarriage are apparently the most suitable for expectant management.

Management of missed abortion in a patient with congenital uterine anomalies

Uterine anomalies are rare entities, vary from 0.1 to 4%, and are related to an increase risk of obstetrical complications. We report a case of a uterine anomaly, diagnosed during the management of a patient who presented with a missed abortion.

First trimester diagnosis of dicephalic parapagus conjoined twins via transvaginal ultrasonography

Conjoined twins are rare, and most cases are thoracopagus. Parapagus conjoined twins (one body with two heads) are extremely rare. We report a case of dicephalic parapagus twins that was diagnosed in the first trimester at 10 weeks via transvaginal ultrasonography.

A prospective study of ultrasound screening for molar pregnancies in missed miscarriages

OBJECTIVE

To examine the relationship between ultrasound and histological features in the screening for molar changes in missed miscarriage.

METHODS

A prospective cohort study was conducted on all missed miscarriages, with features suspicious of molar pregnancy, on transvaginal ultrasound and/or on histological examination over a 5-year period. All cases of molar pregnancy diagnosed histologically were examined and cross-referenced with cases diagnosed on ultrasound and with the supplementary report from the regional referral center. When available, maternal serum beta-human chorionic gonadotropin (hCG) levels were recorded.

RESULTS

Fifty-one cases of suspected molar pregnancy were referred to the regional center for further histological opinion and follow-up, and five cases were subsequently excluded from the final analysis because of the diagnosis of hydropic abortion (HA). In 33 cases a molar pregnancy was suspected at the initial scan. Of these, 26 (78.8%) were confirmed on histology, resulting in a 56% detection rate using ultrasound alone. In 15 cases hCG results were available, of which nine were greater than two multiples of the median.

CONCLUSIONS

The diagnosis of both complete (CHM) and partial (PHM) hydatidiform moles in first-trimester miscarriages is difficult. hCG is significantly higher in both CHM and PHM and, in conjunction with transvaginal ultrasound, could provide the screening test required to enable clinicians to counsel women more confidently towards non-surgical methods of management of their miscarriage, where histopathological examination is not available.

Medical abortion at 9–13 weeks' gestation: a review of 1076 consecutive cases

OBJECTIVE

The aim of the study was to assess the use, efficacy and factors influencing the outcome of medical abortion at 9-13 weeks' gestation.

METHODS

Retrospective chart review of consecutive women undergoing medical abortion at 9-13 weeks' gestation was done.

RESULTS

A total of 1927 abortions were carried out at 9-13 weeks' gestation, of which 1076 (55.8%) were undertaken medically. Efficacy decreased with increasing gestation (p=.02). Surgical evacuation was carried out in 45 (4.2%) women including 10 (2.7%) at 64-70 days, 11 (3.3%) at 71-77 days, 10 (5.1%) at 78-84 days and 14 (8.0%) at 85-91 days of gestation (p=.02). Indications for surgery included continuing pregnancy [16 (1.5%) women], retained sac [5 (0.5%)], incomplete abortion [20 (1.9%)] and emergency curettage for bleeding [4 (0.4%)]. The number of misoprostol doses used and the induction-to-abortion interval both significantly increased with gestation (p<.001), while analgesia requirements did not vary with increasing gestation (p=.18).

CONCLUSIONS

Medical abortion at 9-13 weeks' gestation is an effective alternative to surgery. Medical methods should be offered routinely at these gestations, thus increasing women's choice.

Improved accuracy of hysteroembryoscopic biopsies for karyotyping early missed abortions

OBJECTIVE

To assess the potential of direct embryo and chorion biopsies obtained by hysteroembryoscopy for karyotyping early missed abortions.

DESIGN

Clinical prospective descriptive study.

SETTING

Instituto Valenciano de Infertilidad, Valencia, Spain.

PATIENT(S)

Sixty-eight women (71 gestational sacs) with missed abortions. The gestational age on ultrasound was 6.3 weeks (range, 4-10 weeks).

INTERVENTION(S)

Transcervical hysteroembryoscopy before curettage.

MAIN OUTCOME MEASURE(S)

Comparison between the cytogenetic results from hysteroembryoscopic biospies and those of the curettage material.

RESULT(S)

Hysteroembryoscopic biopsies could be taken in 97.2% of the gestational sacs. Direct embryo and chorion biopsies were suitable for chromosomal analysis. Selective samples identified misdiagnoses of the conventional curettage karyotype due to maternal contaminating tissues in 22.2% of the cases. Direct hysteroembryoscopic biopsies also enabled the diagnosis of a true placental mosaicism and the study of the individual karyotype of each gestational sac in bizygotic twin missed abortions.

CONCLUSION(S)

In early missed abortions, karyotypes from direct hysteroembryoscopic biopsies were more accurate than those from the curettage material. The finding of a 46,XX karyotype in the curettage material is not a reliable result.

Management of missed abortion: comparison of medical treatment with either mifepristone + misoprostol or misoprostol alone with surgical evacuation. A multi-center trial in Copenhagen county, Denmark

OBJECTIVE

To compare the efficacy of two different medical treatment regimens: mifepristone 600 mg orally + misoprostol 0.4 mg vaginally (Mf + Ms) or misoprostol 0.4 mg vaginally (Ms) with conventional surgical evacuation (SE) in women with missed abortion.

MATERIALS AND METHODS

Prospective crossover study with alternating regimens every 4 months. The three university clinics of Obstetrics and Gynecology in Gentofte, Herlev and Glostrup of Copenhagen County. During the period October 1999 to October 2000, 176 women with missed abortion accepted to participate in the study.

RESULTS

The proportion of women who needed surgical evacuation after medical treatment, number of women who needed re-evacuation after primary surgical evacuation, duration of vaginal bleeding, treated infections, need of analgesics, and the subjective experiences from the participating women. Fifty-four, 73 and 49 patients were randomized to Mf + Ms, Ms and SE, respectively. Within 1 week, complete expulsion occurred in 40 (74%), 52 (71%), 47 (96%) of the three arms, respectively. Duration of bleeding was 6.9, 7.1 and 2.5 days in the three arms, respectively (p < 0.01). Women with an initial plasma chorionic gonadotrophine (p-hCG) between 2000 and 20 000 IU/l and a gestational age less than 75 days had a significantly better response to the medical treatment than those not fulfilling these two criteria. Initial p-progesterone did not correlate with success of medical treatment.

MAIN OUTCOME MEASURES

Proportion of women who needed surgical evacuation after medical treatment, and the number of women who needed re-evacuation after primary surgical evacuation, duration of vaginal bleeding, treated infections, the need of analgesics, and subjective experiences from participating women.

CONCLUSION

Vaginal misoprostol 0.4-0.6 mg is effective in most patients with missed abortion. Pre-treatment with the antiprogesterone mifepristone does not increase the success rate. The selection of women with missed abortion for medical treatment based on gestational age and initial p-hCG level may increase the success of medical treatment significantly.

The role of Seprafilm bioresorbable membrane in the prevention and therapy of endometrial synechiae

This randomized controlled blind prospective study is undertaken to evaluate the safety and efficacy of Seprafilm--a novel bioresorbable membrane of chemically modified hyaluronic acid and carboxymethylcellulose--in prevention and reduction of postoperative endometrial and endocervical synechiae formation after general suction evacuation or curettage for incomplete, missed, and recurrent abortion. In total, 150 patients with incomplete or missed abortion participated in the clinical study. The study population was divided into two main groups. In the treatment (Seprafilm) group (n=50), application of Seprafilm membrane in the endometrial cavity and the cervical canal was used after the suction evacuation and/or the curettage. In the control group (n=100), nothing was inserted in the uterus. Both groups were divided into two subgroups: patients who had no previous suction or curettage, (with no previous D&C) (n=88), and patients who had at least one previous suction or curettage (with one or more previous D&C) (n=62). In the treatment (Seprafilm) group, 32 patients had no previous D&C and 18 patients had one or more previous D&C. In the control group, 56 patients had no previous D&C and 44 patients had one or more previous D&C. Further fertility was estimated by pregnancy success in all groups. Endometrial synechiae formation was evaluated with the use of hysterosalpingography (HSG) in patients of all groups without pregnancy success 8 months after the intervention. Registering any adverse reaction and performing ultrasound controls assessed the safety of Seprafilm use. From the subgroup with no previous D&C, all 32 patients (100%) who received Seprafilm had a pregnancy in the following 8 months; in the controls, pregnancy occurred only in 54%. It was also demonstrated with hysterosalpingography (HSG) that patients with one or more previous interventions and no pregnancy 8 months later were adhesion free in 90% of the patients where Seprafilm was used, and only 50% in the untreated group. The membrane was tested on the endometrial area of the uterus and did not produce any adverse reaction. Ultrasound controls did not show any abnormal echoes. Intrauterine insertion of Seprafilm is safe, prevents the appearance of endocervical adhesions or endometrial synechiae after curettage, and reduces the area of the endometrial cavity occupied by them in a large percent of cases. It also seems that its use improves the possibility of a new pregnancy and fertility.

[Acquired hemophilia A after an early abortion]

HISTORY

A 30-year-old woman was referred to our clinic because she had developed recurrent spontaneous hematomas of both calves within the last 2 months. 6 months earlier the patient had developed an ovarian hyperstimulation syndrome after ovarian stimulation treatment and intrauterine insemination. Shortly afterwards a missed abortion (8 (th) week) had been diagnosed. A curettage was carried out.

INVESTIGATIONS

Routine coagulation tests confirmed a prolongation of aPTT to 90 s and a lupus anticoagulant. A high-titre factor VIII inhibitor (56 Bethesda units) was identified.

TREATMENT AND COURSE

Given these facts an acquired post-partum hemophilia was diagnosed. The patient was treated with prednisolone and immunoglobulins. The aPTT shortened to normal values. The factor VIII inhibitor and lupus anticoagulant disappeared. There were no further hematomas.

CONCLUSIONS

The simultaneous occurrence of antibodies in an altered immune state such as pregnancy is well known. In our case, acquired factor VIII inhibitor was found after an early abortion. Treatment with steroids and immunoglobulines led to the disappearance of factor VIII inhibitor and lupus anticoagulant.

Medical termination of missed abortion

Missed abortions are a common occurrence and represent a heavy gynaecological emergency workload to both medical and nursing staff. The conventional method using vacuum aspiration of uterus is associated with morbidity and mortality. Medical termination of pregnancy is accepted as a safe and effective alternative method. However, medical evacuation of uterus in missed abortions had not been fully investigated. In this study we hope to examine the efficacy of medical methods for terminating missed abortions. Mifepristone and misoprostol prescribed to 100 women with an ultrasonically confirmed missed abortion was compared with 100 women who had surgical evacuation under general anaesthesia for their missed abortion. The disparity in complications between medical and surgical groups was not significantly different (Student's t-test, P=0.5). This study showed medical evacuation of missed abortion to be an effective, safe and cost-effective, alternative to surgical evacuation of the uterus and is particularly suited to women not wanting hospital admission or a surgical procedure under general anaesthesia. It represents an option of management that can be less intrusive and gives the woman some control but is both safe and effective.

Entrapment of viable trophoblastic tissue in a uterine hematoma after surgical evacuation. A case report

BACKGROUND

Postevacuation uterine perforation is a common event. Early diagnosis and management are important to minimize the associated morbidity and mortality.

CASE

A woman presented with persistent vaginal bleeding for two weeks following surgical uterine evacuation for missed abortion at 7 weeks' gestation. She had a persistently elevated serum human chorionic gonadotropin level. Ultrasonography revealed a 3-cm, heterogeneous mass with high vascularity at the left anterior uterine fundal region; the endometrial echo was normal. Cornual pregnancy was suspected, and surgical resection was planned. Intraoperatively, a uterine hematoma with evidence of previous uterine perforation was diagnosed. Hysterotomy, removal of the hematoma and repair of the uterus were performed. Histologic examination revealed entrapment of trophoblastic tissue in the specimen. The patient had an uneventful recovery.

CONCLUSION

Entrapment of trophoblastic tissue in a uterine hematoma is a rare sequel of uterine perforation after evacuation and might be confused with cornual pregnancy.

A prospective randomized control trial comparing medical and surgical treatment for early pregnancy failure

A prospective randomized control trial was designed to assess the effectiveness of single dose, 800 microg misoprostol administered p.v. compared with surgical evacuation for the treatment of early pregnancy failure. A total of 80 women with a diagnosis of early pregnancy failure were randomized to study (vaginal misoprostol) and control (surgical curettage) groups. Success of treatment, side-effects as assessed during, immediately after and 10 days after treatment, and patient satisfaction were compared. Intravaginal misoprostol was successful in 82.5% (33 out of 40) of the patients. None of the control group patients required a repeat evacuation. The number of patients who experienced significant abdominal pain following treatment did not differ between the groups. The duration of pain was shorter in the control group; however, they required more analgesics during this short period. The number of patients with significant vaginal bleeding, the duration or severity of bleeding did not show any significant difference between the groups. All 33 patients in the study group who had successful treatment expressed satisfaction, whereas only 58% of the control group did so. In conclusion this randomized control study demonstrated the efficacy and safety of the administration of 800 microg of misoprostol p.v. for the management of early pregnancy failure.

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.