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Purpose To describe the clinical characteristics of children and adolescents that underwent diagnostic laparoscopy for suspected adnexal torsion (AT), and to develop a prediction model for preoperative detection of AT among young women. Methods A retrospective cohort study. We included all girls ≤18 years old with clinically suspected AT who underwent a diagnostic laparoscopy between 3/2011 and 6/2020. We compared patients with AT to those without AT and constructed a prediction model. Results Overall, 120 children and adolescents with suspected AT were included in the study. Of those, AT was identified in 83 (69.2%). In a multivariate analysis, the following risk factors were independently associated with AT and included in the prediction model: absence of right lower quadrant tenderness upon examination [adjusted odds ratio (aOR) (95% Confidence interval (CI)) 3.23 (1.23–8.47), p = 0.017], platelets level >240 K [aOR (95% CI) 3.15 (1.19–8.36), p = 0.021], and neutrophils level >5.4 [aOR (95% CI) 2.71 (1.02–7.52), p = 0.046]. The rate of AT was 12.5% in cases without risk factors for AT, 56.7% with one, 68.8% with two, and 94.1% with three risk factors present, respectively. Conclusions We have identified preoperative indicators independently associated with surgically confirmed AT in a large cohort of young women. Level of evidence- III

OBJECTIVE To evaluate whether the adnexal twist degree is related to torsion recurrence and whether there is a dose-dependent correlation. DESIGN A retrospective cohort study. SETTING Single tertiary medical centre. POPULATION The study includes non-pregnant patients operated, for the first time, for adnexal torsion, between 2011 and 2018. METHODS Information regarding the degree of adnexal twist was collected from surgical reports. Recurrence was identified using a computerised database and ascertained via telephone with a response rate of 87.2% (253/290). MAIN OUTCOME MEASURES Adnexal torsion recurrence rate. RESULTS A total of 182 women who had undergone laparoscopic detorsion met the inclusion criteria. Twenty-two had torsion recurrence (12.1%). Adnexal twist degree in the primary event was associated with a higher recurrence risk: 4.3% of women with twist degree ≤360 (n = 3/70), 14.5% of women with twist degree of 361-720 (n = 9/62) and 20% of women with twist degree >720 (n = 10/50) (P = 0.03). The median twist degree was 540 (interquartile range [IQR] 360-855) and 720 (IQR 675-1080) degrees in the control and study groups, respectively (P = 0.005). Additional possibly associated factors for recurrence were evaluated. Age emerged as a possible risk factor, with a median age of 19 years in the recurrence group (IQR 14-27 years) versus 28.5 (IQR 19-36 years) in the non-recurrence group (P

OBJECTIVE To develop a risk score for preoperative prediction of recurrent adnexal torsion (rAT) among women with a history of previous adnexal torsion (AT). METHODS A retrospective cohort study. We included women with a history of AT, presenting with suspected rAT who underwent diagnostic laparoscopy between March 2011 and March 2020. We compared women with rAT to those without. We constructed a prediction score and validated it in a prospectively collected cohort between April 2020 and June 2020. RESULTS One hundred and fifteen women composed the study cohort. Recurrent AT was confirmed laparoscopically in 86 (74.8%) cases. A risk score for rAT was developed, based on three associated factors: enlarged ovary, no previous oophoropexy and current IVF treatment. In the construction cohort, the rate of torsion was 44.4%, 67.9%, 82.9% and 100% if none, one, two, or three risk factors were present, respectively. In the prospective validation of the risk score, the prediction of one and two risk factors was 60.0% and 100% respectively. CONCLUSION Enlarged ovary is independently associated with preoperative rAT diagnosis. Coupled with information regarding the previous surgical approach in previous AT and current IVF use, these factors could be used to efficiently predict rAT among women with a previous AT.

To compare the prevalence of placental abnormalities in pregnancy following different modes of operative myomectomy.A retrospective cohort study, including all women after myomectomy that gave birth in a single tertiary care center from February 2011 to January 2019. Data was collected from the patients' medical files and completed by telephone questionnaire. Patients were stratified to 3 groups, according to the mode of operative myomectomy (laparotomy, laparoscopy, hysteroscopy). Groups were compared for women demographics, fibroid's characteristics, operative management, post-operative placental evaluation and delivery characteristics. Primary outcome was defined as the need for any intervention for placental separation during the third phase of the delivery.Two hundred forty one women met inclusion criteria. Complete follow-up was achieved in 199 (82.57%) women, of whom 82, 89, and 28 underwent laparoscopic, laparotomy and hysteroscopic myomectomy, respectively. There were no in-between groups differences in women's age, BMI, and gravidity. Disruption of the endometrial cavity during laparoscopy and laparotomy was reported in 3 (3.6%) and 7 (7.8%) cases, respectively (Subsequent pregnancy following surgical myomectomy was not found to be associated with higher prevalence placental abnormality. Furthermore, other than manual lysis, the different modes of myomectomy did not necessitate any further intervention for complications associated with abnormal placentation requiring intervention.Subsequent pregnancy following surgical myomectomy is not associated with higher prevalence of placental abnormality.

A pseudoaneurysm of the uterine artery or its branches is usually a result of vascular trauma during invasive procedures such as a cesarean section, vaginal delivery, myomectomy, hysterotomy, or dilatation and curettage. A uterine artery pseudoaneurysm rupture is a rare, yet life-threatening event. Deep infiltrating endometriosis usually involves a decrease in symptoms and imaging findings throughout pregnancy, with the notable exception of the phenomenon of decidualization. We present the case of a pregnant woman with a recent diagnosis of endometriosis, who conceived spontaneously and presented with disabling pain at 13 weeks' gestation. She was diagnosed with a left, huge (and rapidly growing) retrocervical endometriosis nodule encompassing a uterine artery pseudoaneurysm. Selective transarterial embolization was performed at 22 weeks' gestation owing to enlargement of the pseudoaneurysm sac, and the pseudoaneurysm was obliterated successfully. The patient was followed intensively throughout the pregnancy and the baby was delivered at term by cesarean section. After delivery, the nodule returned to the pregestational size.

Background Technological advances have led to the development of state-of-the-art simulators for training surgeons; few train basic surgical skills, such as vessel ligation. Methods A novel low-cost bench-top simulator with auditory and visual feedback that measures forces exerted during knot tying was tested on 14 surgical residents. Pre- and post-training values for total force exerted during knot tying, maximum pulling and pushing forces and completion time were compared. Results Mean time to reach proficiency during training was 11:26 min, with a mean of 15 consecutive knots. Mean total applied force for each knot were 35% lower post-training than pre-training (7.5 vs. 11.54 N (N), respectively, p = 0.039). Mean upward peak force was significantly lower after, compared to before, training (1.29 vs. 2.12 N, respectively, p = 0.004). Conclusions Simulator training with visual and auditory force feedback improves knot-tying skills of novice surgeons.

Background Vessel ligation with a knot is one of the most fundamental tasks surgeons must master. We developed a simulator designed to enable novices to acquire and refine gentle knot tying capabilities. Methods A bench-top, knot-tying simulator with computer-acquired assessment was tested on expert surgeons and surgery residents at an academic medical center during the years 2016 to 2018. Each participant tied a total of 8 knots in different settings (superficial versus deep) and techniques (1-handed versus 2 hands). The simulator measured vertical forces and task completion time. Results Fifteen experienced surgeons and 30 surgery residents were recruited. The expert group exerted considerably less total force during placement of the knots than the novice residents (3.8 ± 2.0 vs 9.2 ± 6.1 N, respectively; P = .0005) and the peak force exerted upward was less in the expert group (1.31 ± 0.6 vs 1.75 ± 0.84 N; P = .02). The experts also completed the task in less time (10.9 ± 3.4 vs 18.3 ± 7.2 seconds; P = 0.001). Conclusion The simulator can offer residency programs a low-cost, bench-top platform to train and assess objectively the knot-tying capabilities of surgery residents.

OBJECTIVE: To develop a standardized sonographic evaluation and reporting system for Cesarean scar pregnancy (CSP) in the first trimester, for use by both general gynecology and expert clinics. METHODS: A modified Delphi procedure was carried out, in which 28 international experts in obstetric and gynecological ultrasonography were invited to participate. Extensive experience in the use of ultrasound to evaluate Cesarean section (CS) scars in early pregnancy and/or publications concerning CSP or niche evaluation was required to participate. Relevant items for the detection and evaluation of CSP were determined based on the results of a literature search. Consensus was predefined as a level of agreement of at least 70% for each item, and a minimum of three Delphi rounds were planned (two online questionnaires and one group meeting). RESULTS: Sixteen experts participated in the Delphi study and four Delphi rounds were performed. In total, 58 items were determined to be relevant. We differentiated between basic measurements to be performed in general practice and advanced measurements for expert centers or for research purposes. The panel also formulated advice on indications for referral to an expert clinic. Consensus was reached for all 58 items on the definition, terminology, relevant items for evaluation and reporting of CSP. It was recommended that the first CS scar evaluation to determine the location of the pregnancy should be performed at 6-7 weeks' gestation using transvaginal ultrasound. The use of magnetic resonance imaging was not considered to add value in the diagnosis of CSP. A CSP was defined as a pregnancy with implantation in, or in close contact with, the niche. The experts agreed that a CSP can occur only when a niche is present and not in relation to a healed CS scar. Relevant sonographic items to record included gestational sac (GS) size, vascularity, location in relation to the uterine vessels, thickness of the residual myometrium and location of the pregnancy in relation to the uterine cavity and serosa. According to its location, a CSP can be classified as: (1) CSP in which the largest part of the GS protrudes towards the uterine cavity; (2) CSP in which the largest part of the GS is embedded in the myometrium but does not cross the serosal contour; and (3) CSP in which the GS is partially located beyond the outer contour of the cervix or uterus. The type of CSP may change with advancing gestation. Future studies are needed to validate this reporting system and the value of the different CSP types. CONCLUSION: Consensus was achieved among experts regarding the sonographic evaluation and reporting of CSP in the first trimester. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. ispartof: ULTRASOUND IN OBSTETRICS & GYNECOLOGY vol:59 issue:4 pages:437-449 ispartof: location:England status: published

Aim To investigate the clinical and the sonographic characteristics of adnexal torsion (AT) during pregnancy and to underline differences in AT manifestation between pregnancy trimesters. Methods This is a retrospective cohort study in a tertiary medical center. The study included all pregnant women with surgically confirmed AT between March 2011 and April 2020. The patients were divided into three groups according to pregnancy trimesters, and the clinical and sonographic characteristics were compared between the groups. Results The study cohort included 140 cases of AT. Ninety-nine (70.7%) of the cases occurred during the 1st trimester, and 31 (22.1%) and 10 (7.1%) occurred during the 2nd and the 3rd trimesters, respectively. Conception by assisted-reproductive technologies (ART), nausea, and finding of enlarged ovary on ultrasound scan were all more common among patients in the 1st trimester group as compared to the 3rd trimester group (p = 0.001, 0.015, and 0.024, respectively). The mean time from admission to surgery was significantly shorter in the 1st trimester group as compared to late pregnancy (p = 0.001). The majority of cases were right-sided. There was a significant difference in the organs involved in every trimester of pregnancy-ovary only, ovary and fallopian tube, and fallopian tube only (p = 0.023). Conclusions Most AT cases during pregnancy occurred during the 1st trimester. Conception by ART and enlarged ovary on ultrasound scan were also more common in AT cases during early pregnancy. Time from admission to surgery was longer as pregnancy progressed and organs involved differed between trimesters. Understanding the difference in manifestation of AT in every trimester might improve the preoperative evaluation of AT in pregnancy.

The incidence of caesarean scar pregnancy (CSP) increases in recent years. Yet, the best mode of treatment and its effects on successive pregnancies is not well established. The aim of this study was to investigate the success rate of single-dose methotrexate (MTX) in the management of CSP, and the outcomes of subsequent pregnancies in a retrospective cohort study. All women who were treated for CSPs between the years 2011 and 2019 were included. Treatment included systemic MTX and ultrasound-guided needle aspiration (UGNA) in cases with active foetal heartbeat. Overall, 34 women were diagnosed with CSP, of whom 31 were treated with systemic MTX. Twelve patients (38.7%) needed additional curettage or hysteroscopy. The only identified risk factor for failure of MTX-based treatment was time interval between the previous caesarean delivery and CSP (22 vs 34 months, p = 0.04). Twelve women had a subsequent pregnancy. Five pregnancies ended in term delivery, three in preterm delivery, three in abortion and one woman had a recurrent CSP. The study conclusion is that a single dose MTX with UGNA in cases of active heartbeat is an effective mode of treatment in cases of CSP with good sequential pregnancy outcomes. Longer time interval from the previous caesarean delivery was identified as a risk factor for failure of conservative management.

To evaluate pregnancy outcomes of women with surgically confirmed adnexal torsion (AT) as compared to those in whom AT was ruled out.A retrospective cohort study in a tertiary medical center. All pregnant women who underwent diagnostic laparoscopy due to suspected AT between 3/2011 and 4/2020 were included. We compared maternal, delivery and neonatal outcomes of both groups. We further compared women with confirmed AT to a control group of women who did not undergo laparoscopy during pregnancy.During the study period, 112 women met the inclusion criteria. AT was confirmed in 93 cases (83.0%). Baseline characteristics did not differ between groups, excluding the rate of previous AT [5.4% in the torsion vs. 26.3% in the no-torsion group, odds ratio (OR) 0.15, 95% confidence interval (CI) 0.04-0.62,Pregnancy outcomes among women who underwent laparoscopy for a suspected AT during pregnancy were reassuring, irrespective of the surgical findings and gestational week. Outcomes did not differ when compared to pregnant women who did not undergo laparoscopy.Maternal, fetal and neonatal outcomes among women who underwent laparoscopy for suspected adnexal torsion during pregnancy are reassuring, irrespective of the surgical findings and gestational week.

The study aimed to perform external validation of the International Ovarian Tumor Analysis (IOTA) classification of adnexal masses as benign or malignant in women with suspected endometrioma. A retrospective study including women referred to an endometriosis tertiary referral center for dedicated transvaginal ultrasound (TVUS). Adnexal masses were evaluated using the IOTA classification simple descriptors, simple rules and expert opinion. The reference standard was definitive histology after mass removal at laparoscopy. In total, 621 women were evaluated and divided into four groups: endometrioma on TVUS and confirmed on surgery (Group 1 = 181), endometrioma on TVUS but other benign cysts on surgery (Group 2 = 9), other cysts on TVUS but endometrioma on surgery (Group 3 = 2), masses classified as other findings or suspicious for malignancy on TVUS and confirmed on surgery (Group 4 = 5 potentially malignant, 11 benign). This gave a sensitivity 98.9%, specificity 64%, positive 95.3% and negative 88.9% predictive values, positive 2.74 and negative 0.02 likelihood ratios and 94.7% overall accuracy. The surgical diagnosis for the five masses suspected to be malignant was: borderline serous tumor (2), borderline mucinous tumor (2), and endometrioid lesion with complex hyperplasia without atypia (1). The conclusions were that the IOTA classification simple descriptors, simple rules and expert opinion performs well for classifying adnexal masses suspected to be endometrioma. The most common potentially malignant masses in these women were borderline ovarian tumors.

Study Objective To study the collateral effect of the actions taken to limit the spread of the COVID-19 pandemic by comparing the characteristics and outcomes of women who underwent laparoscopy for suspected adnexal torsion (AT) during the pandemic to pre-pandemic periods. Design A retrospective cohort study. Setting A tertiary, university affiliated medical center. Patients or Participants We included all women who underwent laparoscopy for suspected AT between March 2011 and February 2021. We compared the COVID-19 pandemic period, beginning at the first lockdown in Israel (March 15 2020, to February 8 2021, group 1) to a parallel period in 2019-2020 (group 2) and to a nine years period preceding the pandemic, between 3/2011-2/2020 (group 3). Interventions Diagnostic and operative laparoscopy. Measurements and Main Results Ninety-seven laparoscopies were performed in group 1, 82 in group 2, and 635 in group 3. Groups 1 and 2 were comparable in age, obstetrical history, sonographic characteristics of adnexa and clinical presentation. The rate of women presenting following IVF treatment was lower in group 1 [OR 95% CI 0.22 (0.06-0.86), p

We aim to assess the outcome of the treatment of cesarean scar pregnancy (CSP) with single-dose methotrexate (MTX) versus multiple-dose MTX protocols. A retrospective cohort study including two tertiary medical centers was conducted. All women diagnosed with CSPs between the years 2011 and 2019 that were initially managed with systemic MTX were included. Single-dose MTX practiced in one medical center was compared to multiple-dose MTX, practiced in the other medical center. The study cohort included 31 women in the single dose and 32 women in the multiple-dose MTX groups. Baseline characteristics did not differ between groups. The primary outcome occurred in 12 (38.7%) of the cases in the single-dose group and in 6 (18.8%) in the multiple-dose group (p = 0.083). The rate of conversion to surgical treatment was similar in both groups (4 vs. 5 in the single vs. multiple-dose groups, respectively, p = 0.758). There was no significant difference between the single- and the multiple-dose groups in the administration of blood products (16.1% vs. 3.1%, respectively, p = 0.104), total days of admission (18 ± 9.3 vs. 17 ± 12.8 days, respectively, p = 0.850), and readmission rate (32.3% vs. 21.9%, respectively, p = 0.353). Data regarding sequential pregnancies were available for 11 women in the single and 13 women in the multiple-dose MTX groups. There were no differences between the groups in rates of term deliveries, CSP recurrence, and abortions. Both single- and multiple-dose MTX treatment protocols offer high success rate with a relatively low complication rate in the treatment of CSP.

Objective To generate guidance for detailed uterine niche evaluation by ultrasonography in the non‐pregnant woman, using a modified Delphi procedure amongst European experts. Methods Twenty gynecological experts were approached through their membership of the European Niche Taskforce. All experts were physicians with extensive experience in niche evaluation in clinical practice and/or authors of niche publications. By means of a modified Delphi procedure, relevant items for niche measurement were determined based on the results of a literature search and recommendations of a focus group of six Dutch experts. It was predetermined that at least three Delphi rounds would be performed (two online questionnaires completed by the expert panel and one group meeting). For it to be declared that consensus had been reached, a consensus rate for each item of at least 70% was predefined. Results Fifteen experts participated in the Delphi procedure. Consensus was reached for all 42 items on niche evaluation, including definitions, relevance, method of measurement and tips for visualization of the niche. A niche was defined as an indentation at the site of a Cesarean section with a depth of at least 2 mm. Basic measurements, including niche length and depth, residual and adjacent myometrial thickness in the sagittal plane, and niche width in the transverse plane, were considered to be essential. If present, branches should be reported and additional measurements should be made. The use of gel or saline contrast sonography was preferred over standard transvaginal sonography but was not considered mandatory if intrauterine fluid was present. Variation in pressure generated by the transvaginal probe can facilitate imaging, and Doppler imaging can be used to differentiate between a niche and other uterine abnormalities, but neither was considered mandatory. Conclusion Consensus between niche experts was achieved regarding ultrasonographic niche evaluation. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology., This article's abstract has been translated into Spanish and Chinese. Follow the links from the abstract to view the translations. This article has been selected for Journal Club. Click here to view slides and discussion points.

Study Objective To compare expectant versus interventional management of Heterotopic pregnancies. Design A retrospective cohort study, from January 2011 to December 2020. Setting Single tertiary care center. Patients or Participants All women diagnosed with heterotopic pregnancy on ultrasound examination during the study period. Interventions Data were collected from women's' medical files including demographic, laboratory and ultrasound findings, management of heterotopic pregnancy, intrauterine pregnancy, follow up and delivery characteristics. Expectant and interventional management outcomes were compared. Data are presented as median and interquartile range. Measurements and Main Results Forty-one women were diagnosed with heterotopic pregnancy during the study period, of them 73.2% (n=30) following IVF treatment. Abdominal pain was the most frequent presenting symptom (n=25.6%). Ectopic pregnancy was diagnosed in the fallopian tubes in 36 (87.8%) of the women. Management was expectant in 10 (24.4%) and interventional in 31(75.6%) of the women. Expectant management was considered when patient was stable, and ectopic pregnancy did not continue to develop. Interventions included laparoscopic salpingectomy (n=26), laparoscopic cornual resection (n=2), laparotomic cornual resection (n=1) and gestational sac aspiration (n=2). Ongoing intra-uterine pregnancy was achieved in 6 (60%) and 77%(n=17) of the women in the expectant and interventional groups, respectively. All of the women managed expectantly reached term delivery, as opposed to 22 (71.0%) in the intervention management group (p=0.60). Multivariate analysis including: Age, vaginal bleeding, BHCG and management treatment, found BHCG as the only independent parameter associated with ongoing pregnancy rate (p=0.04). Conclusion Both expectant and interventional management were found to be acceptable when heterotopic pregnancy is diagnosed with high ongoing intra-uterine pregnancy rate and term deliveries. BHCG was found as the only independent parameter associated with the ongoing rate.

Study Objective As the experience of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) has been accumulating, it has been questioned whether it can serve as an alternative approach for laparoscopic salphingo-oopherectomy for BRCA mutation carrier women, due to challenging accessibility and perhaps limited visualization of the abdominal cavity. The aim of this study is to report preliminary results using the vNOTES approach for risk reducing bilateral salphingo-oopherectomy for BRCA carrier women. Design A retrospective cohort study, February 2019 to January 2021. Setting Single medical center. Patients or Participants BRCA mutation carrier women that underwent risk reducing bilateral salphingo-oopherectomy via vNOTES approach. Interventions Data were collected from women's' medical files including demographics, medical and obstetrical history, operative characteristics and pathology results. All operations were performed by a single high skilled surgeon. Primary outcome was defined as successful bilateral salpingo-oopherectomy removal by vNOTES approach. Measurements and Main Results Thirty-seven women met inclusion criteria. Of them, 43% (n=16) and 57% (n=21) BRCA1 and BRCA2 mutations carriers, respectively, and 8% (n=3) both mutations carriers. Median age conducting risk reducing operation was 41(IQR39-54) years. Median parity was 2(2-3) with none of the women having past cesarean deliveries. All operations were completed using the vNOTES approach only. Diaphragmatic screening was reported normal in all of the women. No complications were documented in any of the operations including: Bleeding, damage to adjacent organ and need to transfer to laparoscopy. Operation median time was 60(57-68) minutes. All women were released from hospitalization the following day of the surgery. On follow up visit a month post operation, only one woman reported withdrawal bleeding, and all others reported being satisfied from the operation. Histo-pathological examination were clear in all of the women. Conclusion Risk reducing bilateral salphingo-oopherectomy by vNOTES provides a feasible new approach for the treatment of BRCA mutation carriers, with improved women comfort and better cosmetic results.

Objective Cesarean-induced niche can cause symptoms such as abnormal postmenstrual bleeding, pain and associated infertility. Hysteroscopic niche resection is usually a successful treatment, but can result in a failure to improve symptoms or symptoms can recur. In the present study we aim to evaluate the feasibility, effectiveness, and safety of a second hysteroscopic niche resection for patients in whom an initial hysteroscopic resection failed to improve symptoms. Study design This retrospective cohort study (Canadian Task Force classification II-2) hospital tell hashomer (tertiary center) included all patients who underwent a second hysteroscopic niche resection between 2011 and 2015. Measurements:Fertility,obstetric outcomes, clinical outcome and complications were compared between the first surgery and the second Results Eight patients underwent a second hysteroscopy after failure of the first hysteroscopy to resolve symptoms or after recurrence of symptoms. Abnormal uterine bleeding (AUB) was the most common symptom, occurring in all patients. The average number of days of bleeding per cycle were significantly reduced following the second surgery [14.50 (range 8-21 days) vs 11.75 (range 8-20 days), respectivelyp = 0.009]. The second surgery improved symptoms in 6 out of the 8 patients with AUB and 1 of 2 patients with pain. There were no significant differences in fertility and obstetric outcomes between the first and the second surgery and no complications were reported during any of the surgeries. Conclusion Reintervention with a second hysteroscopic niche resection is both feasible and effective treatment option following a failed first attempt or recurrence of symptoms. The second surgery improved symptoms, especially AUB, with no consequent detrimental effect on obstetric outcomes on our series.

Study Objective To develop a risk score for surgically proven recurrent adnexal torsion (rAT), among women with a previous adnexal torsion proven surgically. Design A retrospective cohort study between 2011 and 2020. Setting A tertiary, university affiliated medical center. Patients or Participants All women with a history of surgically confirmed adnexal torsion, who underwent surgical diagnostic procedure due to a suspected rAT. Overall, 115 women were included. Interventions Operative laparoscopy. Measurements and Main Results We collected demographic and clinical characteristics, sonographic findings and laboratory results of all suspected rAT cases that subsequently underwent surgery. We compared cases with adnexal torsion to cases without, as confirmed by operative laparoscopy. Adnexal torsion was identified in 86 (74.8%) of the surgical procedures. Age and pregnancy rates were similar in both groups. Women with adnexal torsion had less prior pelvic surgeries (excluding prior adnexal torsion) [OR(95%CI) 0.24(0.09-0.59), p=0.001], prior oophoropexy [OR(95%CI) 0.36(0.13-0.97), p=0.04] or right adnexal tenderness [OR(95%CI) 0.21 (0.08-0.52), p After multivariate analysis, four risk factors remained significantly independently associated with adnexal torsion. Previous pelvic surgery [aOR(95%CI) 0.06(0.007-0.54), p=0.01] and right side pain [aOR(95%CI) 0.05(0.008-0.33), p=0.002] were negatively associated with adnexal torsion. A larger maximal diameter of the affected ovary [aOR(95%CI) 1.78(1.08-2.93), p=0.02] and enlarged ovary [aOR(95%CI) 7.40(1.28-42.59), p=0.02] were positively associated with adnexal torsion. Conclusion Our risk score enables to predict a true positive rAT that may assist clinicians in decision management in cases of suspected rAT.

Study Objective Office operative hysteroscopy (See-and-treat) allows most women with abnormal ultrasound findings suspected for retained products of conception (RPOC) to avoid the added risks of anesthesia and the inconvenience of the operating room. The aim of this study is to compare office to conventional operative hysteroscopy for the treatment of RPOC. Design A retrospective cohort study from January 2018 to March 2019. Setting Single tertiary medical care center. Patients or Participants All women who underwent hysteroscopy due to RPOC during the study period. Interventions Data were collected from women's medical records. Primary outcome was defined as successful removal of all suspected RPOC. Data are presented as median and interquartile range. Measurements and Main Results During the study period, 229 women underwent hysteroscopy due to RPOC, of them 141 (61.57%) and 88 (38.43%) office and conventional operative hysteroscopy, respectively. No in-between group differences were observed in women's age, body mass index and parity. Time interval to hysteroscopy was longer [ 2.13 (1.55-2.78) vs. 1.63 (1.02-1.63) month; p=0.001], and maximal diameter of thesuspected finding was smaller for the office group compared to the conventional operative group [12.0 (8-20) vs. 20 (15-30) mm; p=0.001]. Positive finding rate on histho-pathology was higher for the operative group (76.1% vs. 61.0%; p=0.02). Additional analysis comparing success (n=111) to failure (n=30) of office operative hysteroscopy, revealed that maximal diameter ≤27.5 mm had significantly higher success rate (p=0.007). This finding was supported by logistic regression analysis that found maximal diameter of the suspected finding as the only parameter associated with success rate in office operative hysteroscopy (B=0.12; p=0.001). Conclusion Office operative hysteroscopy is a feasible treatment option for the removal of RPOC when maximal content dimeter is taken under consideration due to its association to success rate.

Study Objective To develop a risk score calculator for the prediction of adnexal torsion during pregnancy. Design A retrospective cohort study between 3.2011-4.2020. Setting Tertiary medical center. Patients or Participants All women who underwent surgical diagnostic procedure due to suspected adnexal torsion in pregnancy. Overall, 156 women were included. Interventions Operative laparoscopy. Measurements and Main Results We collected demographic and clinical characteristics. The presence or absence of adnexal torsion during the surgical procedure was recorded. Adnexal torsion was identified in 131 (83.9%) of the surgical procedures. The rate of previous ovarian torsion was lower in the torsion group [OR(95%CI) 0.29(0.11-0.79), p=0.01]. Pregnancy following assisted reproductive technology (ART) was more common in the torsion group [OR(95%CI) 7.0(1.99-24.54), p

Ovarian endometriomas are cysts on or within the ovarian parenchyma that contain chocolate-like fluid. Ovarian endometriomas are a typical manifestation of the disease, and their prevalence is between 17% and 44% of patients with endometriosis (Jenkins et al., Obstet Gynecol 67(3):335–338, 1986; Redwine, Fertil Steril 72(2):310–315, 1999; Busacca and Vignali, Curr Opin Obstet Gynecol 15:321–326, 2003).

With interest we read the correspondence of Bamberg et al.1 and Scioscia et al.2 about the randomized controlled trial of the first authors concerning the uterine niche after caesarean section (CS).3 They state that at the time of the trial it was not established which technique should be used in the evaluation of a caesarean scar or niche in daily practice and future research. Both authors underline the need for a uniform evaluation of the CS scar establishing an internationally accepted definition of a niche. In their study a niche was defined as an anechogenic area at the site of the uterine scar with a depth of at least 1 mm. This article is protected by copyright. All rights reserved. ispartof: ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA vol:98 issue:10 pages:1351-1352 ispartof: location:United States status: published

Study Objectives To describe the management of interstitial pregnancies in a tertiary medical center, identify factors associated with treatment failure, and report subsequent pregnancy outcome. Design Retrospective cohort study. Setting Department of Gynecology in a tertiary medical center. Patients All women who were admitted to and treated for interstitial pregnancy at our center between 2011 and 2019. Interventions The women were originally assigned to undergo expectant, medical, or surgical treatment. The women's background and clinical data were compared according to initial treatment modality. Nonsurgical (expectant and medical) management outcomes were analyzed to identify risk factors for treatment failure. Subsequent pregnancy outcomes were described separately. Measurement and Main Results Thirty-seven cases of interstitial pregnancy were identified. There were high rates of pregnancy achieved by in vitro fertilization (45.9%) and a history of ipsilateral salpingectomy (43.2%) among these patients. At presentation, the mean age of the study cohort was 34.76 years, and the median β-human chorionic gonadotropin level was 3853.0, and median gestational age was 7.0, respectively. The nonsurgical management success rate was 70.0%. Uterine rupture occurred during treatment in 5 cases (16.6%). Gestational sac diameter significantly affected treatment failure (p = .03), and a diameter >20 mm was observed in all cases of failed non-surgical treatment. Data on future fertility was available for 21 (58.3%) women: 13 (61.9%) had a subsequent pregnancy, 1 of which was a recurrent interstitial pregnancy. The median interpregnancy interval was 8.1 months, and all but 3 pregnancies reached third trimester and resulted in a live birth, with an overall cesarean delivery rate of 61.5%. None of the subsequent pregnancies were complicated by uterine rupture, and no serious adverse outcomes were noted in any of the subsequent intrauterine pregnancies that reached third trimester. Conclusion Successful nonsurgical management of an interstitial pregnancy is feasible, although appropriate selection of cases is advised. A large gestational sac is a risk factor for treatment failure and should prompt surgical intervention. Subsequent pregnancies can generally be considered safe and with a favorable outcome.

Purpose: To determine the success rate of induction of labor (IOL) using Foley transcervical balloon (FTB) versus prostaglandin E2 (PGE2) vaginal insert, following failure of cervical ripening with PGE2 vaginal insert.Materials and methods: A retrospective cohort study of all pregnant women admitted for IOL with either FTB or PGE2 vaginal insert. Either second dose of PGE2 vaginal insert or FTB was used as a second line treatment after failure (not giving birth in 24 h from insertion) of first PGE2 vaginal insert.Results: During the study period, 1162 women were admitted for IOL. Failure was reported in 322/852 (37.8%) in the FTB versus 162/310 (52.2%) in the PGE2 group (p

Study Objective To investigate the predisposing factors for recurrent adnexal torsion (rAT) in patients who had surgical intervention for primary adnexal torsion (pAT). Design A retrospective cohort study between 2011 and 2020. Setting A tertiary, university affiliated medical center. Patients or Participants 358 women with a primary occurrence of surgically proven adnexal torsion. Interventions Adnexal detorsion, with adjuvant cystectomy, salpingectomy or salpingoophorectomy by laparoscopy. Measurements and Main Results We collected demographic and clinical characteristics, sonographic findings and laboratory results of all pAT episodes. We compared those who had experienced rAT to those who had not. The study included 358 women. Of those, 35 (9.8%) had a rAT. Women who experienced rAT were younger (mean age 26 vs. 30, p=0.01) with higher proportion of age ≤15 [Odds Ratio (OR) 95%CI 4.4(1.80-11.1)]. A history of hysterectomy was positively associated with rAT [3(8.6%) vs. 1(0.3%), p=0.003]. Pregnancy rates during pAT were comparable between study groups. However, rAT was associated with lower gestational age at pAT (mean 9 weeks vs. 12 weeks, p=0.01) and conception by assisted reproductive technologies [OR 95%CI 6.0(1.21-29.65), p=0.02]. Clinical characteristics did not differ between groups except smaller ovarian cyst diameter in those with rAT (mean 42 vs. 59 mm. p Conclusion Recurrent adnexal torsion is more common than previously thought. Younger age and smaller ovarian cyst at pAT are independently associated with the risk for future recurrence of adnexal torsion. These factors should be considered when contemplating oophoropexy at pAT.

Study Objective To report pregnancy success rate and pregnancy outcome in women following cesarean scar defect (niche) repair. Design A retrospective cohort study from July 2014 to March 2019. Setting Single medical care center. Patients or Participants All women after laparoscopic niche repair done by a single high skilled surgeon, during the study period. Interventions Data was collected from women's medical records and a telephone interview was performed to assess further symptoms and attempts to conceive, including pregnancy outcomes. Measurements and Main Results During the study period 48 women underwent laparoscopic niche repair, of them complete follow-up was achieved for 37 (78.7%) women. Median age was 35 years (IQR 32-39) with median of one cesarean delivery in the past (IQR 1-1). The median residual myometrial thickness measured by ultrasound before the repair was 2.0 mm (IQR 1.4-2.5). Attempts to conceive were reported by 81% (n=30) of the women, while 18 (60%) achieved pregnancy in median time of 6 month (IQR 5-12) post niche repair. 14 (78%) of the women conceived spontaneously. No placental abnormalities were reported in any of the women. All gave birth by cesarean delivery at a median of 38.4 gestation week (IQR 37.0-39.5). No uterine dehiscence or rupture were reported. Conclusion Pregnancy following cesarean scar defect repair can be achieved with low pregnancy complication rate and good pregnancy outcomes. Further studies need to be done in order to strengthen our findings.

Study Objective The relationship between various niche features and symptoms has not fully been elucidated. The aim of this study is to evaluate the association between the presence of niche to the presence of symptoms. Design A prospective cohort study conducted between December 2018 to March 2020. Setting Single tertiary medical center. Patients or Participants Women that underwent cesarean delivery during January 2011 to December 2018. Interventions All women were requested to arrive at the gynecological clinics. During their visit they completed questionnaire regarding symptoms related to the presence of niche (menorrhagia, spotting, pelvic pain and infertility) . A trans-vaginal 2-D ultrasound examination targeted to assess the uterine scar characteristics was performed. Primary outcome was defined as the presence of uterine niche evaluated by length, depth, residual myomtrial thickness (RMT) and the proportion between residual to adjacent myometrial thickness (RMT/AMT). Data are presented as median and Interquartile range. Measurements and Main Results Two hundred twenty-five women were included in the study. 128 (56.88%) and 97 (43.11%) were symptomatic and asymptomatic, respectively. Median time from delivery to follow-up was 16 months for both of the groups. RMT was the only measurement associated with symptoms. RMT Conclusion Residual myometrial thickness was found associated with infertility. All other niche measurements were comparable between symptomatic and asymptomatic women. Further investigation is required to strengthen this finding.

Study Objective To assess the outcome of the treatment of cesarean scar pregnancy (CSP) with single dose methotrexate (MTX-SD) versus multiple dose MTX (MTX-MD) protocols. Design A retrospective cohort study from two tertiary medical centers between the years 2011-2019. Setting N/A Patients or Participants The study cohort included all CSPs cases from the two centers. 32 women in the MTX-SD and 32 women in the MTX-MD groups. Interventions MTX-SD, practiced in one medical center, included a single dose of systemic MTX-SD followed by ultrasound guided needle aspiration of the gestational sac in cases with fetal heartbeat. MTX-MD, practiced in the other medical center, included four consecutive doses of MTX, and local KCL in cases with fetal heartbeat. Characteristics and outcomes were compared between both groups. Measurements and Main Results Baseline characteristics did not differ between groups. In the MTX-SD group, the median dose number was one, versus three in the MTX-MD group. In 16 (50%) of the cases of the MTX-SD and in 12 (37.5%) of the cases of the MTX-MD, fetal heartbeat was present and US guided aspiration or KCL injection were performed, respectively. There was no significant difference between the MTX-SD and the MTX-MD groups in total days of admission (17±9.3 vs. 17±12.8 days respectively, p=0.94), need for invasive procedures (12.5% vs. 18.7% respectively, p=0.24), readmission rate (31.3% vs. 21.9% respectively, p=0.39) and need of blood products (15.6% vs. 3.1% respectively, p=0.19). Conclusion Both MTX-SD and MTX-MD protocols offer high success rate with a relatively low complication rate in the treatment of CSP, with no significant differences between groups.

Study Objective To compare the clinical characteristics and sonographic findings of adnexal torsion between pregnancy trimesters. Design A retrospective cohort study between 2011 and 2020. Setting A tertiary, university affiliated medical center. Patients or Participants Overall, 122 pregnant women with 131 separate episodes of surgically proven adnexal torsion. Interventions Laparoscopy for confirmation and treatment of adnexal torsion. Measurements and Main Results We collected demographic and clinical characteristics as well as sonographic findings and laboratory results of all adnexal torsion episodes. We compared the three trimesters of pregnancy. Overall, 92 of the episodes occurred during 1st trimester, 29 and 10 occurred during 2nd and 3rd trimester, respectively. The majority of cases were right sided (61%). Pregnancy achieved following assisted reproductive technology (ART) was more common in the 1st trimester group (p 6 was more common in 1st and 3rd trimester, compared to 2nd trimester (p=0.02). Gastrointestinal symptoms were also more common among patients in the 1st trimester (p The mean diameter of affected adnexa was similar in all trimesters, while the non-affected adnexa was marginally significantly smaller in the 2nd and 3rd trimesters. In approximately one third of all cases ultrasound findings included at least one specific feature: edematous ovary, absent doppler flow or presence of whirlpool sign. Absent doppler flow was more common in the 2nd and 3rd trimester compared to the 1st trimester (p Duration from admission to surgery was significantly longer in the 2nd and 3rd trimesters (p=0.002). Conclusion We found differences in the clinical, sonographic and laboratory manifestations of adnexal torsion in each trimester of pregnancy. When assessing pregnant patients with suspected adnexal torsion, these differences may assist in ameliorating an accurate diagnosis.

Study Objective Laparoscopic management of nonobstetric acute abdominal pain in the third trimester of pregnancy remains controversial with limited data regarding procedure safety and feasibility. This study aimed to investigate the feasibility, immediate complications, and short-term outcomes of laparoscopic surgery at an advanced gestational age. Design Case-series. Setting Sheba Medical Center, a tertiary referral center. Patients Pregnant women who underwent urgent laparoscopic surgery at 27 weeks of gestation and above. Intervention Emergent laparoscopic surgery. Measurements and Main Results Clinical data were retrospectively collected and analyzed. A telephone questionnaire was administered in cases of missing data. Clinical information obtained included detailed medical and obstetric history; preoperative, intraoperative, and postoperative data; complications; and pregnancy outcomes. Between January 2010 and July 2017, 12 patients underwent emergent laparoscopic surgeries during the third trimester of pregnancy. The gestational age at the time of the surgery ranged between 27 and 38 weeks. All women had singleton pregnancies. Laparoscopic surgeries included 7 appendectomies, 4 adnexal surgeries, and 1 diagnostic laparoscopy. No complications related to the access route for any of the 12 laparoscopic surgeries occurred. The laparoscopic surgical procedure was successfully completed in 11 patients; only 1 laparoscopic appendectomy for perforated acute appendicitis with purulent peritonitis at 30 weeks of gestation was converted to laparotomy because of a limited operative field. Two patients had preterm labor at 35 and 36 weeks of gestation, respectively. None of the women was complicated with intrauterine fetal demise or low Apgar scores. Conclusion Our results demonstrate that urgent laparoscopic surgeries in the third trimester of pregnancy are feasible and can be safely performed with minimal risk for the patient and fetus. Larger prospective studies are required to validate these recommendations.

Cesarean scar defect (CSD) is often associated with postmenstrual bleeding, infertility, and pain. Hysteroscopic CSD repair was described in the past, mainly as excision of the proximal edge of the defect to allow continuous blood flow during menstruation. In this study we aimed to evaluate the efficacy of extensive hysteroscopic cesarean scar niche excision in symptomatic patients.A retrospective cohort study.Symptomatic patients treated with hysteroscopic CSD excision who were considered eligible for the procedure when myometrial thickness of 2 mm or more was observed on sonohysterography.Tertiary referral center.Extensive CSD excision was performed using a cutting loop and pure cutting current. The proximal and distal edges of the defect were resected. This was followed by resection of tissue at the base of the niche, until underling muscular tissue was evident. Tissue sampled from the base of the CSD was collected for histologic examination. Patients were followed for a minimum of 1 year after hysteroscopic CSD excision. Clinical information obtained included detailed obstetric history and preoperative and postoperative menstruation pattern.Between 2011 and 2016, 95 patients underwent extensive hysteroscopic niche excision; 67 were included in the study, whereas the remaining were lost to follow-up. Patient mean age at the time of the procedure was 38 ± 5.5 years. Twenty-nine patients (43%) had a history of high-order repeat cesarean surgeries. Sixty-six patients (98.5%) presented with postmenstrual bleeding, 26 with secondary infertility (38.8%), and 2 with pelvic pain (2.9%). After hysteroscopic niche excision, 63.4% of patients reported significant improvement or resolution of postmenstrual bleeding. A statistically significant reduction in number of bleeding days per cycle (15.5 ± 4.8 vs 9.8 ± 4.7, p.001) was also noted. Histologic evidence for myometrial tissue within the obtained samples was associated with better outcomes. A histologic specimen from patients who experienced significant improvement or resolution of postmenstrual bleeding was more likely to reveal myometrial tissue (p = .04). Of the 26 patients who suffered from infertility, 19 attempted to conceive spontaneously after CSD excision. Of those, 10 patients (52.6%) conceived and 9 delivered at least once (47.36%).Extensive hysteroscopic surgical excision of cesarean scar niche should be considered in symptomatic patients suffering from irregular menstrual bleeding. The quality of the excision at the apex of the niche could be associated with a higher success rate. The role of niche excision to overcome secondary infertility should be further evaluated.

Objective To determine the association between early increase in the serum hCG levels (days 0–4) and treatment success rates following methotrexate therapy in ectopic pregnancy patients. Study design A level II-2 case-control study of involving 140 patients treated with methotrexate for ectopic pregnancy at the gynecology department in a tertiary care hospital. Results A logistic regression model for the "failure of treatment" was fitted with serum hCG levels change between day 0 and day 4, patient age, pregnancy age at day-0, and day-0 β-hCG level as predictors. The logistic regression analysis indicated that having more than 50% increase in the β-hCG levels between days 0 and 4 significantly (P = 0.011) increases the risk of MTX treatment failure. Conclusion The results of this study indicate that >50% increase in β-hCG levels between days 0 and 4 significantly increases the risk of methotrexate treatment failure. This novel information could assist patients and physicians in making decisions regarding ectopic pregnancy treatment.

Study Objective To compare the incidence of placental abnormalities in subsequent pregnancy after myomectomy performed by laparoscopy, laparotomy and hysteroscopy. Design A retrospective cohort study, conducted from February 2011 to November 2018. Setting A single tertiary care center. Patients or Participants All women after myomectomy that gave birth. Interventions Data was collected from patients' medical files. Groups were compared for women demographics, fibroids characteristics, operative management, post-operative placental evaluation and delivery characteristics. Primary outcome was defined as the need for any intervention for placental separation during the third phase of the delivery. Non-parametric statistics were used for analysis. Measurements and Main Results 241 women met inclusion criteria. Complete follow-up was achieved in 199 (82.57%) women, of them 82, 89 and 28 underwent laparoscopic, laparotomy and hysteroscopic myomectomy, respectively. There were no significant differences between the groups in women's age, BMI, gravidity and history of cesarean deliveries. Endometrial damage during laparoscopy and laparotomy was reported in 3 (3.6%) and 7 (7.8%) of the women, respectively (p=0.21), and in all women undergoing hysteroscopic myomectomy (p=0.001). During subsequent pregnancy, morbidly adherent placenta was suspected in only one woman in each of the groups (p=0.63), a rate that is considered lower than the reported rate after one cesarean delivery. Placenta previa was not seen in any of the women included in the study. Normal vaginal delivery was significantly higher in the hysteroscopy group compared to laparoscopy and laparotomy groups [11 (36.3%) vs. 5 (6.1%) vs. 4 (4.5%); p=0.001], with significantly lower need for manual lysis of the placenta [11(39.0%) vs. 51 (62.1%) vs. 62 (69.7%); p=0.01] and no need for any further interventions to control blood loss. Conclusion Subsequent pregnancy after myomectomy was not found to be associated with high placental abnormality rate. Furthermore, other than manual lysis, no difference in abnormal placentation requiring intervention was seen between the different techniques.

Objective Intracavitary uterine fibroids and fibroids that distort the uterine cavity are associated with excessive vaginal bleeding and infertility. While intracavitary fibroids smaller than 4 cm are usually treated safely by operative hysteroscopy, larger fibroids may require multiple surgeries or more extensive surgery with possible damage to the integrity of the uterine wall. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a noninvasive approach for treating uterine fibroids, mainly the intramural type. We present the outcome of MRgFUS treatment for intracavitary fibroids (FIGO class 1) in cases that could not be treated by hysteroscopy due to either fibroid size or patient refusal. (Canadian Task Force II-1). Study design A retrospective cohort study from a single tertiary referral center. A total of 68 patients were treated by MRgFUS for symptomatic uterine fibroids from January 2013 to December 2016. Six of them had FIGO class 1 fibroids. Adverse effects and short- and long-term outcomes (quality of life issues and need for additional surgical intervention) were assessed during ambulatory clinic visits and by phone interviews. Results The mean ± SD fibroid volume on MRI screening was 86.3 ± 60.9 cm3. Six of those patients underwent the procedure (mean age 40.5 ± 5.6 years, range 33–48). The follow-up duration was 24.1 ± 12.0 months. Four patients were not interested in future fertility and did not undergo additional treatment, while the two who planned to conceive underwent another surgical intervention (one underwent operative hysteroscopy after reduction of fibroid size and the other underwent laparoscopic myomectomy). Conclusion This preliminary study shows that MRgFUS can be a feasible treatment option for FIGO class 1 uterine fibroids. Shrinkage of fibroids by MRgFUS can obviate or facilitate subsequent surgical intervention in selected cases.

Study Objective To compare the long-term outcome of laparoscopic myomectomy with MR-guided focused ultrasound (MRgFUS) for symptomatic uterine fibroids. Design A cohort study, from January 2012 to January 2017. Setting Single tertiary care center. Patients or Participants All patients with symptomatic uterine fibroids treated operatively with laparoscopic myomectomy or treated conservatively with MR-guided focused ultrasound. Interventions A telephone interview was performed to assess further interventions and sustained fibroid associated symptoms using the Uterine Fibroid Symptom and Quality of Life symptom severity score (UFS-QOL-SSS). Measurements and Main Results One-hundred fifty-four women met the inclusion criteria. Complete follow-up was achieved for 64 women underwent laparoscopic myomectomy and 68 were treated by MRgFUS. Follow up time was similar for both groups (median, IQR: 31 month, (17-51) vs 36 month (24 - 41); P=0.95, respectively). The rate of additional interventions was 5 (7.8%) and 9 (13.2%), respectively (p=0.312). Similarly, the uterine fibroid symptom-quality of life-symptom severity score (QOL-SSS) questionnaire at follow up interview revealed comparable score 17(12-21) vs 17 (13-22) for laparoscopic myomectomy and MRgFUS, respectively (p=0.439). Analyzing each of the symptoms separately (bleeding, changes in menstruation, abdominal pain, bladder activity, nocturia, fatigue), did not change these findings. Conclusion Long term outcome and surgical intervention following MRgFUS treatment for uterine fibroids seems comparable with that laparoscopic myomectomy. Further larger randomized trials are needed to confirm these findings.

Study Objective To determine an effective method of intrauterine device (IUD) retrieval from pregnant women who had previous unsuccessful ultrasound-guided IUD extraction failure. Design A retrospective cohort study (Canadian task force classification II-1). Setting A gynecology department of an outpatient clinic. Patients Pregnant patients in their first trimester with IUD in situ who underwent prior unsuccessful ultrasound-guided IUD extraction. Interventions Hysteroscopic IUD extraction guided by transabdominal ultrasound. Measurements and Main Results Between 2011 and 2014, 7 of 8 pregnant patients who had undergone previous failed attempts at IUD retrieval via ultrasound guidance underwent successful removal via ultrasound-guided hysteroscopy performed without anesthesia. The sole patient with extraction failure was in her 12th week of pregnancy, and the procedure was concluded to avoid risk to the fetus. Minimal vaginal bleeding was experienced by 2 patients after the procedure. Seven of 8 patients delivered at term without any obstetric complications. One patient had a miscarriage in her 8th week of pregnancy, 2 weeks after successful IUD removal. Conclusion A novel, easy outpatient hysteroscopic technique without anesthesia is presented in case of failure of previous ultrasound-guided IUD removal in early pregnancy. Results are encouraging in this difficult context.

Aims: To determine the clinical yield of abdominal ultrasound in the evaluation of elevated liver enzymes (ELEs) in the second and the third trimester of pregnancy. Methods: A retrospective cohort study including all pregnant women admitted to a single tertiary care center was conducted between April 2011 and January 2015 with ELE. Inclusion criteria included gestational age above 24 weeks and ELEs, abdominal ultrasound report, and live fetus. Exclusion criteria included known maternal liver disease, structural or chromosomal fetal anomalies, and positive serology for viral hepatitis. All patients underwent abdominal ultrasound. A significant finding of this study led to a change in treatment. Results: One hundred and twenty patients (41.8%) met inclusion criteria: 93 (77.5%) had a normal scan and 27 (22.5%) had abnormal findings. Significant ultrasound findings were found only in 2 (1.6%) patients: gallstones in the common bile duct and suspected autoimmune hepatitis. There were no significant differences between patients with and without ultrasound findings in the rate of cholestasis of pregnancy, preeclampsia, chronic hypertension, and gestation diabetes. Conclusion: Abdominal ultrasound examination in this population has a low clinical yield. The decision to perform an abdominal ultrasound must be individualized based on the obstetric history, clinical findings, and the level of liver enzymes.

Objective To test whether the follicular fluid (FF) concentration of anti-Mullerian hormone (AMH) is associated with oocyte maturation, fertilization rate, and embryonic development in patients with polycystic ovary syndrome (PCOS) undergoing IVF. Design Prospective. Setting Academic assisted reproductive technology program. Patient(s) Twenty-two samples of FF from 11 patients with PCOS who underwent IVF/ET were analyzed for AMH levels (group A). Twelve women with normal ovulatory cycles served as a control group (group B). The oocytes and preembryos were closely followed until ET. Method(s) FF was obtained at oocyte retrieval for IVF/intracytoplasmic sperm injection. AMH levels were studied using immunoenzymometric assay. Intervention(s) None. Main Outcome Measure(s) FF, AMH levels, oocyte maturation, fertility rate, and embryonic cleavage rate. Result(s) The mean FF AMH level was 57.3 ± 79.5 pmol/mL in group A, compared with 70 ± 120.14 pmol/mL in group B. In group A, the mean AMH level of good-quality embryos was 37.4 ± 23.4 pmol/mL, compared with 61.9 ± 102 pmol/mL in a the poor-quality subgroup. No significant correlation was observed between FF AMH levels and oocyte maturation, fertilization, or cleavage rate. Conclusion(s) This study suggests that there is an association between FF AMH levels and the quality of embryos in patients with PCOS. However, owing to large variance and the number of participants, no statistical significance was reached. The degree of maturation of retrieved oocytes, as well as the success of fertilization, was not found to correlate with FF AMH.

Study Objective To determine the long-term outcome of intrauterine pregnancies after treatment of heterotopic pregnancies. Design Retrospective cohort study (Canadian Task Force classification II-3). Setting Tertiary center university hospital. Patients All women who underwent surgery because of heterotopic pregnancy over 12 years. Intervention Laparoscopic surgery. Measurements and Main Results Infant development and future pregnancy. Extrauterine pregnancies were located in the tube (n = 13), uterine cornua (n = 3), ovary (n = 1), and tubal stump (n = 2). During laparoscopy, a ruptured tube was found in 6 tubal pregnancies (46%), blood transfusion was needed in 7 heterotopic pregnancies (37%), and salpingectomy was performed in 12 women with tubal pregnancies (91.7%). The pregnancy outcome consisted of 13 babies (term and preterm) taken home and 5 miscarriages. Long-term follow up demonstrated that 10 of 13 infants (76.9%) exhibited normal development. Three infants, all from 1 triplet pregnancy, exhibited borderline to normal development. Ten of 15 women achieved additional pregnancies, with 10 deliveries and only 1 extrauterine pregnancy in the tubal stump. Conclusions Women with a heterotopic pregnancy are at high risk for late diagnosis and at risk for hypovolemic shock at diagnosis, and may require blood transfusion. The outcome of intrauterine pregnancy in association with heterotopic pregnancy requiring surgical intervention is good, and most complications were associated with multifetal pregnancy and preterm delivery.

The purpose of the study was to construct a clinical profile of a patient more likely to have ovarian torsion (OT). The study design was a retrospective chart review (Canadian Task Force Classification II-3). The study was done in a tertiary referral center setting. Patients were 78 women who underwent laparoscopy for suspected ovarian torsion. Intervention done was urgent laparoscopic surgery. The main outcome measure was a comparison of demographic data and the presenting signs and symptoms of the women with and without laparoscopically proven OT. Multivariable analysis was performed with a logistic regression model in order to determine the independent risk predictors for OT. The following factors were found to be predictive of OT: vomiting (OR = 5.67, 95% CI 1.69–19.0, p = 0.005); duration of pain less than a day (OR = 3.74, 95% CI 1.24–11.3, p = 0.02), and sudden/nocturnal onset of pain (OR = 4.13, 95% CI 1.19–14.3, p = 0.02). The model was found to be adequate, with a c value of 0.798. A patient presenting with an episode of pain lasting less than a day that started suddenly and or at night, accompanied by vomiting is more likely to have OT on urgent laparoscopy.