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Myasthenia and HELLP syndrome Attilio Di Spiezio Sardo, Alex Taylor, Massimiliano Pellicano, Lucio Romano, Giuseppe Acunzo, Giuseppe Bifulco, Giuseppe Cerrota, Carmine Nappi Department of Gynaecology, Obstetrics, and Pathophysiology of Human Reproduction, University of Naples ‘‘Federico II’’, Via S. Pansini 5, Naples 80131, Italy Minimally Invasive Therapy Unit and Endoscopy Training Centre, University Department of Obstetrics and Gynaecology, Royal Free Hospital, Hampstead, London, UK

Objective To assess the efficacy of autocrosslinked hyaluronic gel in postsurgical adhesion prevention after laparoscopic myomectomy. Design Prospective, randomized, controlled study. Setting University of Naples "Federico II". Patient(s) Thirty-six infertile women with symptomatic myomas were randomly divided into two groups of 18 patients each. Intervention(s) Laparoscopic myomectomy with subserous sutures or interrupted figure 8 sutures, with (group A) or without (group B) application of autocrosslinked hyaluronic acid (HA) gel. Main outcome measure(s) Rate of postsurgical adhesions at 60–90 days of follow-up. Result(s) The rate of subjects who developed postoperative adhesions was significantly lower in group A in comparison with group B (27.8% vs. 77.8%). In both groups, the rate of adhesions was significantly higher in patients treated with interrupted figure 8 sutures than with subserous sutures. Conclusion(s) Autocrosslinked HA gel is a promising resorbable agent barrier for the reduction of postoperative adhesions after laparoscopic myomectomy. Moreover, the type of suture is a factor influencing the postsurgical adhesion formation.

Objective To evaluate the satisfaction rate, efficacy, and complication rate of carbon dioxide (CO 2 ) versus normal saline as a uterine distension medium for outpatient diagnostic vaginoscopic hysteroscopy in infertile patients. Design Prospective, randomized multicenter study. Setting Hysteroscopy units in two university hospitals and in a private center. Patient(s) One hundred eighty-nine infertile women undergoing outpatient hysteroscopy. Intervention(s) Outpatient hysteroscopy was performed with CO 2 (group A) or normal saline (group B) and with endometrial biopsy when indicated. Main outcome measure(s) Quality of the visualization of the uterine cavity, procedure time, complications, patient discomfort, and satisfaction rate. Result(s) Significantly lower abdominal and shoulder tip pain and a lower incidence of vasovagal reactions were observed in group B in comparison with group A. A higher satisfaction rate and a lower operative time were obtained in the normal saline group in comparison with the CO 2 group. Moreover, group A required significantly more analgesics after the procedure than group B. Conclusion(s) Uterine distension with normal saline seems to have less adverse effects and is better tolerated by patients. Moreover, it allows operative procedures to be performed with the new bipolar instruments.

To evaluate the efficacy of intraperitoneal subdiaphragmatic instillation of 0.5% lidocaine and 0.5% bupivacaine infiltration of cannula sites to control pain after diagnostic microlaparoscopy.Prospective, randomized study. (Canadian Task Force classification I).Day surgery unit of Endogyn Service, Private Endoscopic Associates, Naples, and Department of Gynecologic and Pediatric Sciences, Reggio Calabria University, Catanzaro, Italy.Forty women treated for infertility.The treated group received 0.5% intraperitoneal subdiaphragmatic lidocaine 40 ml and 0.5% bupivacaine 5 ml infiltration of cannula insertion sites. The control group received no treatment. In all patients the procedure was performed with atropine 0.5 mg, fentanyl 0.1 mg, droperidol 5 mg, and local anesthesia. Postoperatively, depending on the need, ketoprofene 100 mg or ketorolac 30 mg was administered intramuscularly.Postoperative pain score was evaluated by visual analog scale immediately postoperatively and 1, 3, 6, 12, 24, 36, and 48 hours afterward. The treated group had significantly lower pain scores at the end of surgery and at 1-, 3-, (p0.01), and 6-hour intervals (p0.05). No significant differences in scores between groups were observed starting from 6 hours postoperatively.Postoperative intraperitoneal lidocaine and bupivacaine infiltration of cannula sites offered a detectable benefit to women undergoing diagnostic microlaparoscopy. The effect was temporary, but induced a significant decrease in the postoperative pain for approximately 6 hours.

Heterotopic pregnancy (HT) in the absence of a previous ovarian hyperstimulation is a very rare condition. Transvaginal ultrasonography (TV) in the case of first trimester pelvic pain allows a high diagnostic reliability in the identification of HT and a successful conservative treatment by means of TV potassium chloride injection.

Background: The use of methotrexate (MTX) by systemic administration in the treatment of unruptured ectopic pregnancy has been reported as a safe and effective method. Cases: We report three cases (one hematosalpinx and two pelvic hematocoeles) of complications after the use of MTX in the treatment of unruptured ectopic pregnancies. All three cases came to our observation for pelvic pain, abnormal bleeding and a pelvic mass after an interval of 3–5 months, subsequent to the disappearance of symptoms and normalization of serum human chorionic gonadotropin β-subunit (β-hCG) levels. Conclusions: These findings suggest that: (a) such complications should be considered before selecting the mode of treatment for ectopic pregnancy; and (b) that an early ultrasonographic control should be performed after MTX treatment even when the decline in β-hCG levels suggests a successful resolution. This would permit an early diagnosis of these late complications.