AIM:

The aim of this study was to respectively evaluate the feasibility and safety of bilateral uterine artery chemoembolization (UACE) combined with dilation and curettage (D&C) for the treatment of cesarean scar pregnancy (CSP).

MATERIAL AND METHODS:

Our study was approved by our institutional review board, with informed patient consent. From January 2004 to December 2010, 79 patients with CSP underwent UACE in our institution, with transcatheter infusion of 30-50 mg methotrexate into the bilateral uterine artery before embolization with sponge particles. Within 24-48 h after UACE, D&C was performed on all the patients under the guidance of ultrasonography and hysteroscopy.

RESULTS:

All the 79 patients diagnosed as having CSP were included in our study and their data were analyzed. All the patients recovered completely without severe complications. The average hemorrhage volume during D&C was 30 mL, but none of them needed transfusion. The uteri of all the patients were preserved, and none of them had to undergo hysterectomy. The safety rate was 100%. The mean duration of hospital stay was 10.5 days.

CONCLUSIONS:

UACE performed prior to D&C is a feasible method and it may reduce hemorrhage complications and risk of hysterectomy in patients with CSP.

OBJECTIVE:

To investigate the perinatal outcomes of pregnant women with cervical intraepithelial neoplasia (CIN).

METHOD:

The women in this retrospective case-control study were recruited from Beijing Obstetrics and Gynecology Hospital from August 1, 2007 to February 28, 2010. All the cases were 13-32 gestational weeks, who were diagnosed by colposcopy conducted cervical biopsy. A total of 108 cases were followed-up to the day of delivery.

RESULTS:

(1) Complications of colposcopy conducted cervical biopsy: there were two cases of pregnant women, who suffered cervical local compression after undergoing colposcopy conducted cervical biopsy, as the bleeding could not be stopped, the wound was treated by local suture. The incidence of such event was 1.8 % (2/108), without any colposcopy and biopsy-related adverse event. (2) Cesarean section rate was 63.6 % (56/88) in CIN, which was higher than 30.0 % (6/20) in cervicitis, and the cesarean section rate increased as CIN grades elevated, and gestational weeks of delivery advanced.(P < 0.05). (3) We did not detect significant difference for the incidence of polyhydramnios, premature rupture of fetal membranes, placental abruption, cervical laceration and postpartum hemorrhage, low birth weight infants, amniotic fluid II-III degree, neonatal deformity and neonatal asphyxia between pregnant women with CIN and cervicitis (P > 0.05); however, the incidence of oligohydramnios and premature infants in pregnant women with CIN group were higher than that in cervicitis group (P = 0.007; P = 0.020). (4) Vaginal delivery and HR-HPV infection did not increase the incidence of perinatal complication; the volume of postpartum hemorrhage within 2 h after birth in vaginal delivery was less than in cesearean section for pregnancies with CIN (P = 0.000).

CONCLUSION:

Pregnant women with CIN can be diagnosed by colposcopy conducted cervical biopsy, and they should be carefully monitored oligohydramnios and preterm during pregnancy. Pregnant women with CIN during pregnancy, excluding other obstetric operation indications may choose vaginal delivery first.

Placental site nodules (PSNs) and epithelioid trophoblastic tumors (ETTs) respectively represent non-neoplastic and neoplastic lesions of chorionic-type intermediate trophoblasts (ITs). Many patients with a PSN have a history of a cesarean section (CS) or therapeutic abortion. Recent evidence shows that a PSN may progress to an ETT. Herein, we describe a coexisting ETT and placental site trophoblastic tumor (PSTT) intimately associated with PSNs in the post-cesarean lower uterine segment of a 41-year-old woman. The patient presented with abnormal vaginal bleeding 1 year after a cesarean delivery for her most recent pregnancy. We speculated that the neoplasms had transformed from PS Ns, the formation of which was related to faulty expulsion of the placental tissue or abnormal colonization of chorionic-type ITs during the CS. Neoplastic trophoblastic cells derived from PSNs displayed differentiation plasticity toward chorionic-type ITs and implantation site ITs that were respectively constituted of an ETT and PSTT. Virtual slides The virtual slides for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1597949195882123.

Background:

Abnormal uterine bleeding is the direct cause of a significant health care burden for women, their families, and society as a whole. Up to 30% of women will seek medical assistance for this problem during their reproductive years. This guideline replaces previous clinical guidelines on the topic and is aimed to enable health care providers with the tools to provide the latest evidence-based care in the diagnosis and the medical and surgical management of this common problem.

Objective:

To provide current evidence-based guidelines for the diagnosis and management of abnormal uterine bleeding (AUB) among women of reproductive age. Outcomes: Outcomes evaluated include the impact of AUB on quality of life and the results of interventions including medical and surgical management of AUB.

Methods:

Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of location in Canada, type of practice, subspecialty expertise, and general gynaecology background. The committee reviewed relevant evidence in the English medical literature including published guidelines. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC.

Results:

This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of AUB. The resulting recommendations may be adapted by individual health care workers when serving women with this condition.

Conclusions:

Abnormal uterine bleeding is a common and sometimes debilitating condition in women of reproductive age. Standardization of related terminology, a systematic approach to diagnosis and investigation, and a step-wise approach to intervention is necessary. Treatment commencing with medical therapeutic modalities followed by the least invasive surgical modalities achieving results satisfactory to the patient is the ultimate goal of all therapeutic interventions. Evidence: Published literature was retrieved through searches of MEDLINE and the Cochrane Library in March 2011 using appropriate controlled vocabulary (e.g. uterine hemorrhage, menorrhagia) and key words (e.g. menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English and published from January 1999 to March 2011. Searches were updated on a regular basis and incorporated in the guideline to February 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Benefits, harms, and costs: Implementation of the guideline recommendations will improve the health and well-being of women with abnormal uterine bleeding, their families, and society. The economic cost of implementing these guidelines in the Canadian health care system was not considered. Summary Statements 1. AUB is a common condition affecting women of reproductive age that has significant social and economic impact. (II-2) 2. Contemporary terminology used to describe AUB in reproductive-aged women aims to simplify definitions and to provide standard descriptions related to patient presentation. (III) 3. The consequences of AUB on an individual's overall health determine the degree to which intervention may be required. (II-2) 4. A thorough history and physical exam will often indicate the cause of AUB and direct the need for further investigation and treatment (III). 5. Imaging and hysteroscopy offer the clinician additional information to assist in patient assessment and treatment in indicated circumstances. (I) 6. Once malignancy and significant pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option for abnormal uterine bleeding. (I) 7. Medical treatment tailored to the individual woman's therapeutic goals, desire for contraception, underlying medical conditions, and tolerance of side effects will encourage compliance and maximize the likelihood of treatment success. (III) 8. Non-hysteroscopic ablation techniques offer similar patient satisfaction results with fewer risks of complications and less anaesthetic requirement than traditional hysteroscopic ablation. (I) 9. Hysterectomy provides definitive treatment for abnormal uterine bleeding. (I) 10. Abnormal uterine bleeding secondary to submucosal fibroids may be managed by hysteroscopic myomectomy. (I) 11. Inherited bleeding disorders may be an underlying cause of abnormal uterine bleeding, with von Willebrand's disease present in the majority of cases. (II-2) 12. Acute heavy menstrual bleeding may result in significant anemia and emergent care. (III) 13. AUB in the adolescent most commonly represents ovulatory dysfunction related to immaturity of the hypothalamic-pituitary-ovarian axis. (II-2) Recommendations 1. Adoption of standardized international terminology for AUB should be considered (III-C) 2. A complete blood count is recommended for women with heavy or prolonged bleeding. (II-2A) 3. If there is any possibility of pregnancy, a sensitive urine or serum pregnancy test should be performed. (III-C) 4. Testing for coagulation disorders should be considered only in women who have a history of heavy menstrual bleeding beginning at menarche or who have a personal or family history of abnormal bleeding. (II-2B) 5. Thyroid function tests are not indicated unless there are clinical findings suggestive of an index of possible suspicions of thyroid disease. (II-2D) 6. If imaging is indicated, transvaginal ultrasound should be the first line imaging modality for AUB. (I-A) 7. Saline infusion sonohysterography and diagnostic hysteroscopy should be used in the diagnosis and characterization of discrete intrauterine abnormalities such as submucosal fibroids. (I-A) 8. Endometrial biopsy should be considered in bleeding women over age 40 or in those with bleeding not responsive to medical therapy, as well as in younger women with risk factors from endometrial cancer. (II-2A) 9. Office endometrial biopsy should replace dilation and uterine curettage as the initial assessment of the endometrium for these women. (II-2A) 10. Focal lesions of the endometrium that require biopsy should be managed through hysteroscopy-guided evaluation. (II-2A) 11. Non-hormonal options such as NSAIDs and antifibrinolytics can be used effectively to treat heavy menstrual bleeding that is mainly cyclic or predictable in timing. (I-A) 12. Combined oral contraceptive pills, depot medroxyprogesterone acetate, and levonorgestrel-releasing intrauterine systems significantly reduce menstrual bleeding and should be used to treat women with abnormal uterine bleeding who desire effective contraception. (I-A) 13. Cyclic luteal-phase progestins do not effectively reduce blood loss and therefore should not be used as a specific treatment for heavy menstrual bleeding. (I-E) 14. Danazol and GnRH agonists will effectively reduce menstrual bleeding, and may be used for scenarios in which other medical or surgical treatments have failed or are contraindicated. (I-C) 15. Patients receiving a GnRH agonist for longer than 6 months should be prescribed add-back hormone therapy, if not already initiated with GnRH agonist commencement. (I-A) 16. The progestin IUS has outcomes similar to endometrial ablation for women with heavy menstrual bleeding and thus may be considered prior to surgical intervention. (I-A) 17. In appropriate candidates, non-hysteroscopic ablation techniques should be the ablation methods of choice in view of their higher efficacy and safety than hysteroscopic techniques. (I-A) 18. With the exception of NSAIDs, the same medical agents used to treat heavy menstrual bleeding among women with normal coagulation can effectively be used in the setting of inherited bleeding disorders. (II-1B) 19. Women with inherited bleeding disorders who have significant heavy menstrual bleeding or those who fail conventional medical therapy are best managed with a multidisciplinary approach. (III-C) 20. Hysterectomy planning or blood product therapy should be performed in consultation with a hematologist in patients with inherited bleeding disorders. (III-C) 21. Acute heavy menstrual bleeding should be managed promptly and systematically to minimize patient morbidity and the need for blood transfusion. (III-C) 22. High-dose estrogen and tranexamic acid may help decrease or arrest acute heavy menstrual bleeding. (III-C) 23. For the adolescent presenting with heavy menstrual bleeding at or in close approximation to menarche, history and investigations should include an assessment for an underlying bleeding disorder. (II-2A).

Labor induction is being increasingly used (15-30% of pregnancies). The most common indications include late pregnancy preeclampsia, intrauterine fetal growth retardation (IUGR), hypertension. Preinduction by speeding up the ripening of the cervix increases the chances of successful induction. There are mechanical and pharmacological methods of pre-induction: the Foley catheter hygroscopic dilators, prostaglandin gel, misoprostol. There are various schemes of labor pre-induction and the differences relate primarily to duration of catheter time, amniotomy or the start of the oxytocin. Numerous studies on pre-induction and induction of labor aimed to compare the efficacy of these different methods. The effectiveness of the Foley catheter is usually assessed by comparing cervical maturity (Bishop score) and ripening of the cervix, evaluated in centimeters, before and after removing the cathetec time to labor since pre-induction and the number of births. In order to select the appropriate method, its safety for the mother and the fetus/newborn needs to be assessed. According to most authors, the use of a Foley catheter does not cause over-stimulation of the uterus, does not increase the risk of rupture or intrauterine infection, and does not adversely affect the fetus and newborn.To assess the efficacy and safety of labor pre-induction using a Foley catheterThe study included 109 women hospitalized between 03.01.2011 and 11.30.2011, who underwent labor pre-induction with a Foley catheter The inclusion criteria were: one fetal pregnancy longitudinal cephalic fetal position, completed 36 weeks of pregnancy fetal bladder preserved, Bishop score < 5 points. The exclusion criteria were: placenta previa, uterine infection, unexplained bleeding, abnormal fetal heart rate, and other reasons preventing vaginal delivery such as fetal weight above 4500 g. Vaginal swabs for the presence of Streptococcus agalactiae (GBS) were obtained from each patient. In case of a positive result perinatal antibiotic prophylaxis was administered before insertion of the catheter The study group was divided into two subgroups according to parity: primiparous and multiparous. Indications for induction, method of pregnancy termination, the pregnancy and its complications were evaluated. The condition of the newborns was evaluated using the Apgar score, cord blood pH and infant birth weight. We analyzed cervical ripeness (Bishop score) before the insertion and after the removal of the catheter and serum C-reactive protein (CRP) before and 20 hours after insertion. CRP was not studied in pregnant women diagnosed with GBS colonization. The results were compared between the subgroups. An increase in the Bishop score to> 5 and delivery within 12 hours since the planned removal of the catheter regardless of the method of pregnancy and the use of oxytocin, was considered as successful induction of laborCatheter pre-induction was performed in 109 pregnant women, what amounted to 7.87% all of deliveries in our department during the analyzed period. Mean patient age was 29.3 +/- 5.35 years, mean duration of pregnancy 40 weeks of gestation (+/- 1 week 5 days), and primiparas constituted 66.06% of all cases. The most common indication for labor induction was post-term pregnancy (55.05%), hypertension and preeclampsia (16.51%). The following complications were observed in the study group after insertion of the catheter: 8 (7.34%) cases of premature rupture of the membranes (PROM), but none of them occurred in the process of inserting the catheter 11 (10.09%) women had the catheter removed (patients request) due to pain and the feeling of discomfort before the scheduled time, 2 (1.84%) cases of bleeding (in the first case the cesarean section was performed and the baby was born in a good overall condition, in the second case the bleeding subsided spontaneously). There was a statistically significant increase in the Bishop score for the entire study group and in the two subgroups. Mean increase in the Bishop score was 2.68 +/- 1.39 points for the entire cohort (p < 0.005). The rate of successful pre-induction resulting in a delivery was 69.4%, with vaginal births accounting for 66.67% of all cases. Also, 30.66% of the pregnant women did not require the use of oxytocin. The most common indication for cesarean section was threatening intrauterine fetal asphyxia. Higher efficiency of pre-induction was found in the multiparous group. The observed increase in CRP (p < 0.005) was within the normal range for pregnant women (< 12 mg/I). None of the patients showed any clinical signs of infection. Mean birth weight of the infants was 3392 +/- 644.72 g, mean Apgar score was 9.5 +/- 0.80 and mean cord blood pH was 7.3 +/- 0.08.The Foley catheter is an effective method of inducing cervical maturation. The Foley catheter is safe method of labor induction for the mother fetus and newborn.

Hypertensive disorders complicating pregnancy seriously endanger the safety of the mother and fetus during pregnancy. Very few studies have explored hypertensive disorders of pregnancy in India, even though this disease has been associated with adverse maternal and perinatal outcomes. This study aimed to analyze the disease pattern and risk factors associated with the disorder and assess the maternal and fetal outcomes in cases of hypertensive disorders of pregnancy.This case-control study was carried out over 1 year from 2011 to 2012 at the Department of Obstetrics and Gynecology, King George's Medical University, Lucknow, Uttar Pradesh, India. A total of 149 patients were enrolled in the study. As seven were lost to follow-up, analysis was carried out on 142 cases. Patients were further classified according to the National High Blood Pressure Education Program Working Group (2000) as having mild preeclampsia (65 cases), severe preeclampsia (32 cases), or eclampsia (45 cases). Thirty-one healthy pregnant non-hypertensive women were enrolled into the study as controls.The most common manifestation was edema, seen in 90% of cases. Proteinuria was also relatively common, 26.76% of patients with proteinuria of ≥300 mg/24 hours, 47.88% with proteinuria of ≥2 g/24 hours, and 25.35% with a urinary protein excretion of 3-5 g/24 hours. Central nervous system involvement was observed in 42.2% of cases, elevated bilirubin levels in 47.0%, visual symptoms in 6.4%, vaginal bleeding in 11.3%, and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome was reported in 2.80%. Maternal deaths occurred in 2.8% of cases, all of which were from the eclampsia group. Stillbirths occurred in 16.9% of cases, and overall neonatal death observed in 4.23% of cases.Women with hypertensive disorders of pregnancy were more prone to adverse maternal and fetal outcomes than normotensive pregnant women, but we observed a decreasing trend in the present study compared with that reported in other studies, which might be due to the increased number of hospital deliveries that occurred in our study.