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Objective: The purpose of this review was to determine the likelihood of malignancy or complications with ultrasonographic diagnosis of adnexal masses in pregnancy and to evaluate the obstetrical outcomes. Materials and, Methods: A review of literature was performed using keywords "adnexal mass and pregnancy" or "ovarian mass and pregnancy.", Results: Out of the 340 abstracts reviewed, 313 were excluded. The incidence of adnexal mass in pregnancy varied from 0.1 to 2.4%, with an average of 0.02%. Regarding the likelihood of malignancy, in seven publications, there were 557 women with 563 adnexal masses. Of these 563 masses, 48% were classified as simple and 52% as complex. Among the simple masses, 1% were malignant. Among the complex masses, 9% were malignant. When comparing laparoscopy and laparotomy, the rate of preterm contractions was found to be higher in patients undergoing laparotomy and this was statistically significant. Other measures, such as spontaneous abortion, vaginal bleeding, < 37 week delivery, and intrauterine fetal demise, were not found to have a significant difference., Conclusion: Adnexal masses in pregnancy occur infrequently and depending on whether the surgery was performed emergently or electively, via laparoscopy or laparotomy, the outcomes will vary., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To assess 3-year data on the efficacy and safety of a new 52-mg levonorgestrel intrauterine contraceptive (LNG20) designed for up to 7 years use., Study Design: Nulliparous and parous women aged 16-45 years at enrollment with regular menstrual cycles and requesting contraception were enrolled in an open-label, partially randomized trial to evaluate LNG20. The primary outcome was pregnancy rate for women aged 16-35 years calculated as the Pearl Index. Women aged 36-45 years received LNG20 for safety evaluation only. All participants had in-person or phone follow-up approximately every 3 months during the study., Results: A total of 1600 women aged 16-35 years and 151 women aged 36-45 years agreed to LNG20 placement, including 1011 (57.7%) nulliparous and 438 (25.1%) obese women. Successful placement occurred in 1714 (97.9%) women. Six pregnancies occurred, four of which were ectopic. The Pearl Index for LNG20 was 0.15 (95% CI 0.02-0.55) through Year 1, 0.26 (95% CI 0.10-0.57) through Year 2, and 0.22 (95% CI 0.08-0.49) through Year 3. The cumulative life-table pregnancy rate was 0.55 (95% CI 0.24-1.23) through 3 years. Expulsion was reported in 62 (3.5%) participants, most (50 [80.6%]) during the first year of use. Of women who discontinued LNG20 and desired pregnancy, 86.8% conceived spontaneously within 12 months. Pelvic infection was diagnosed in 10 (0.6%) women. Only 26 (1.5%) LNG20 users discontinued due to bleeding complaints., Conclusion: The LNG20 intrauterine system is highly effective and safe over 3 years of use in nulliparous and parous women., Implications Statement: A new 52-mg levonorgestrel-releasing intrauterine system is effective and safe for nulliparous and parous women for at least 3 years., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)

Aims: Placental abruption is an important cause of perinatal mortality and morbidity. Although there are many reports on the risk factors for placental abruption, there are few on its classification. Our aim is to evaluate the associations between primary symptoms and the outcomes of placental abruption., Material and Methods: We carried out a retrospective cohort study of 12,474 births at the Perinatal Center for Maternity and Neonates of the Yokohama City University Medical Center between January 2000 and December 2012. There were 151 women with placental abruption, 136 of whom were included in this study. The subjects were classified into two groups according to their primary symptoms: those with bleeding (external bleeding group) and those with abdominal pain (abdominal pain group). Maternal and neonatal outcomes were compared between the two groups., Results: Both fetal and maternal outcomes were significantly poorer in the abdominal pain group than in the external bleeding group in terms of intrauterine fetal death (6.5% vs 33.3%, P < 0.001), perinatal mortality (8.1% vs 33.3%, P = 0.001), umbilical arterial pH < 7.1 (15.7% vs 57.1%, P < 0.001), bleeding volume, rate of blood transfusion, and disseminated intravascular coagulation incidence., Conclusions: This classification based on primary symptoms was found to be useful for predicting both maternal and neonatal outcomes of placental abruption., (© 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.)

Objective: To analyze reported complications and their treatment after a medical abortion with mifepristone and misoprostol provided by a telemedicine service to women living in Latin America., Methods: Observational study based on the registry of consultations in a telemedicine service. A total of 872 women who used the service in 2010 and 2011 participated in the study. The dependent variables were overall complications, hemorrhage, incomplete abortion, overall treatments, surgical evacuation, and antibiotics. Independent variables were age, area of residence, socioeconomic deprivation, previous children, pregnancies and abortions, and week of pregnancy. We fitted Poisson regression models with robust variance to estimate incidence ratios and 95% confidence intervals (95%CI)., Results: Complications were reported by 14.6% of the participants: 6.2% reported hemorrhage and 6.8% incomplete abortion. Nearly one-fifth (19.0%) received postabortion treatment: 10.9% had a surgical evacuation and 9.3% took antibiotics. Socioeconomic deprivation increased the risk of complications by 64% (95%CI: 15%-132%), and, among these, the risk of incomplete abortion by 82% (95%CI: 8%-206%) and the risk of surgical intervention by 62% (95%CI: 7%-144%). Previous pregnancies increased the risk of complications and, specifically, the risk of hemorrhage by 2.29 times (95%CI: 1.33-3.95%). Women with a pregnancy of 12 or more weeks had a 2.45 times higher risk of receiving medical treatment and a 2.94 times higher risk of taking antibiotics compared with women with pregnancies of 7 or less weeks., Conclusion: Medical abortion provided by telemedicine seems to be a safe and effective alternative in contexts where it is legally restricted., (Copyright © 2014 SESPAS. Published by Elsevier Espana. All rights reserved.)

Objective: To evaluate the incidence of vaginal bleeding in women with placenta accreta according to gestational age at delivery., Methods: This is a retrospective cohort study of women with prior cesarean delivery and persistent placenta previa delivered at our institution between December 1997 and December 2011. Diagnosis of invasion was based on hysterectomy performed for an abnormally adherent placenta with histologic confirmation. Suspicion for invasion was based on the impression of the attending physician at the time of ultrasonography. Records were reviewed to identify indication for delivery and estimated blood loss. Statistical analyses were performed using Student's t test, χ2 test, and Mantel-Haenszel and Jonckheere-Terpstra tests for trend., Results: Of 216 women with prior cesarean delivery and persistent previa, 65 (30%) required cesarean hysterectomy and had histologic confirmation of invasion. Urgent delivery for bleeding was performed in 20% of these pregnancies (13/65). Delivery for bleeding decreased significantly with advancing gestation (P=.001). In our series, 71% with accreta were delivered at 36 weeks of gestation or greater with delivery for bleeding in five (11%), and estimated blood loss was not increased in these pregnancies. Of 79 women with ultrasonographic suspicion for accreta, the incidence of vaginal bleeding prompting urgent delivery also decreased with advancing gestation (P<.001)., Conclusion: Likelihood of vaginal bleeding necessitating delivery declined with advancing gestation in pregnancies with placenta accreta as did blood loss. Most were delivered at 36 weeks of gestation or greater, nearly 90% in the absence of bleeding complications. Thus, although preterm delivery is an important consideration when placenta accreta is suspected, our findings support individualizing delivery planning.

Objective: To describe the frequency, characteristics, and patient outcomes for women who accessed Emergency Medical Services (EMS) for obstetric emergencies at the ports of entry (POE) between El Paso, Texas, United States of America, and Ciudad Juárez, Chihuahua, Mexico., Methods: A descriptive study of women 12-49 years of age for whom an EMS ambulance was called to an El Paso POE location from December 2008-April 2011 was conducted. Women were identified through surveillance of EMS records. EMS and emergency department (ED) records were abstracted for all women through December 2009 and for women with an obstetric emergency through April 2011. For obstetric patients admitted to the hospital, additional prenatal and birth characteristics were collected. Frequencies and proportions were estimated for each variable; differences between residents of the United States and Mexico were tested., Results: During December 2008-December 2009, 47.6% (68/143) of women receiving EMS assistance at an El Paso POE had an obstetric emergency, nearly 20 times the proportion for Texas overall. During December 2008-April 2011, 60.1% (66/109) of obstetric patients with ED records were admitted to hospital and 52 gave birth before discharge. Preterm birth (23.1%; No. = 12), low birth weight (9.6%; No. = 5), birth in transit (7.7%; No. = 4), and postpartum hemorrhage (5.8%; No. = 3) were common; fewer than one-half the women (46.2%; No. = 24) had evidence of prenatal care., Conclusions: The high proportion of obstetric EMS transports and high prevalence of complications in this population suggest a need for binational risk reduction efforts.

Objective: To determine prevalence estimates of gynecological alarm symptoms in different age groups and to describe common patterns of gynecological symptoms., Design: Web-based cross-sectional survey study., Setting: Nationwide in Denmark., Population: A random sample of 51,090 women aged 20 years or above from the general population., Methods: An internet-based questionnaire study regarding the prevalence estimates of symptom experiences. A total of 18 symptoms of cervical, endometrial and ovarian cancer were selected through an extensive literature search, which included national and international guidelines., Main Outcome Measures: Prevalence estimates of self-reported experience of gynecological alarm symptoms within the preceding 4 weeks., Results: A total of 26,466 women (54.5%) participated in the study. Some 80.3% had experienced at least one of the alarm symptoms within the preceding 4 weeks, and the median number of experienced symptoms was 2 (interquartile range 1-4). The most common symptoms were tiredness (53.0%) and abdominal bloating (36.7%); postmenopausal bleeding (2.3%) and involuntary weight loss (2.8%) were least frequent. Most of the symptoms were more prevalent among younger women, whereas only dyspnea and increased urgency of urination were more frequent among older women. Among younger women, multiple abdominal symptoms often occurred simultaneously and frequently in combination with pelvic pain, whereas older women were more likely to report single symptoms., Conclusions: Gynecological alarm symptoms are frequent in the general population, mostly among younger women. Older women reported fewer symptoms, and these often appeared as single symptoms., (© 2014 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: Uterine fibroids (UF) represent the most common benign uterine tumor in women of reproductive age. Symptoms including heavy, prolonged menstrual bleeding, pelvic pain/pressure, and/or urinary frequency have a substantial impact on women's quality of life and utility values for UF have not been published., Methods: Health state descriptions associated with UF symptoms and treatment side effects were developed based on patient focus groups; validated using expert clinical input; and pilot tested for understandability. Using a web-based questionnaire, 909 community-dwelling, Canadian women were surveyed to assess their perceived value associated with these states., Results: Utility for uncontrolled bleeding was 0.55 (95% CI: 0.54, 0.57) and the decrement associated with hot flashes was 0.06 (95% CI: -0.07, -0.04). Utility improvement associated with bleeding control was 0.18 (95% CI: 0.17, 0.19) and with smaller fibroid size was 0.03 (95% CI: 0.02, 0.04)., Conclusion: These values illustrate the high utility associated with control of excessive menstrual bleeding.

Background: The advancement of neonatology over the past 20 years has allowed a greater number of ELBW infants to survive. However, these advancements have contributed to the increased incidence of acute kidney injury (AKI) seen in this population. Understanding the risk factors for AKI in this population of ELBW infants is imperative for the successful survival of these infants since the morbidity and mortality rates from this disease are increasing., Objectives: 1) to determine the prevalence of AKI in ELBW (<  750 grams). 2) to compare the mortality rate of ELBW infants (<  750 grams) with and without AKI; and 3) to identify the associated risk factors of AKI in ELBW infants (<  750 grams)., Methods: A retrospective chart review of all infants with AKI as defined by AKIN criterias, admitted to the NICU between 1998 and 2008 was conducted. Case-controls were matched for BW, gestational age and date of birth, (SPSS v17.0 software, using Student's t test, X2 test, and Mann-Whitney U test were used for statistical analysis., Conclusion: The prevalence rate of ELBW infants (<  750 grams) with AKI admitted at CHMCA NICU from 1998 to 2008 was 26% . The mortality rate of ELBW infants (<  750 grams) with AKI was 54% , compared to 20% in those ELBW infants who did not have AKI. The associated risk factors of AKI in the ELBW infants (<  750 grams) were as follows: presence of maternal placental abruption/bleeding, grade III or IV IVH, PDA, positive culture/s, NEC, use of steroid, nephrotoxic drugs, and longer use of the ventilator and TPN.

Purpose: We aimed to investigate the association of metabolic syndrome and metabolic risk factors with endometrial hyperplasia and carcinoma among women with abnormal uterine bleeding (AUB)., Methods: This study included 199 patients who had undergone endometrial curettage due to abnormal uterine bleeding. We divided the patients into two groups according to whether they had an abnormal (n = 53) or normal endometrium (n = 146). Waist circumference, blood pressure, fasting glucose and serum lipid levels were measured and statistically analyzed. The women in each group were matched with regard to mean age, gravidity, parity and menopausal status., Results: We found increased prevalence of metabolic syndrome, diabetes, general and abdominal obesity, hypertension, elevated levels of glucose, total cholesterol and LDL-cholesterol and reduced levels of HDL-cholesterol among women with endometrial carcinoma and hyperplasia. These results were detected particularly in postmenopausal (>50 years) women compared to pre-menopausal cases (<50 years). All metabolic parameters were similar between hyperplasia and cancer groups., Conclusion: Metabolic syndrome and its components have been shown to have profound impacts on initiation and progession of endometrial pathology, particularly during post-menopausal period.

This prospective observational study was done on 400 perimenopausal patients who presented with abnormal uterine bleeding with selective endometrial lesions diagnosed on histopathology. Patients were followed to determine their response to progestin therapy and their final clinical outcome. The commonest bleeding pattern was menorrhagia (67.5%), the commonest pathology was simple endometrial hyperplasia without atypia (31%). 142 cases with non- atypical endometrial hyperplasia received progestin therapy with follow up, 100 cases (70.4%) experienced lesion regression, 38 cases (26.7%) experienced persistence and four cases (2.9%) experienced progression to atypia. Low dose progestin therapy (< 20 mg/day) was more effective when used for 4-5 months. Hysterectomy was done for 44 cases, due to atypical endometrial hyperplasia, persistence and progression of non atypical hyperplasia. Perimenopausal bleeding is mostly dysfunctional in origin but organic lesions remained a major concern which requires endometrial sampling with proper interpretation to achieve better clinical outcome.

Objective: Subjective social status (SSS) may be a stronger determinant of health than objective measures of socioeconomic status. We sought to examine the effect of community and national SSS on symptoms of depression in a racially/ethnically diverse sample of adult women with noncancerous uterine conditions., Methods: We conducted a secondary analysis of data obtained from 634 women who enrolled in the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA) in 2003 and 2004. SOPHIA was a longitudinal study of women aged 31 to 54 who were experiencing abnormal uterine bleeding, symptomatic fibroids, or pelvic pain. The primary outcome for this analysis consisted of symptoms suggesting major or other depressive disorder, as measured by the Patient Health Questionnaire-9, 2 years after study enrollment. We hypothesized that women who had low community and national SSS at baseline, as measured by the MacArthur SSS ladder, would be at higher risk of experiencing symptoms of depression at follow-up., Results: Women with low community SSS had an increased odds of experiencing depression symptoms 2 years later compared with women with high SSS, after adjusting for age, pelvic problem impact and baseline depression (odds ratio, 2.93; 95% CI, 1.11-7.77). Odds remained elevated after further adjusting for income and education. Results for the national ladder were not significant., Conclusion: Low perceived community social status is predictive of symptoms suggestive of major or other depressive disorder among women with noncancerous uterine conditions. Asking about perceived community social status can help clinicians to identify patients who may be at increased risk for depressive disorders. Asking about perceived national social status does not seem to add value beyond that provided by income and education., (Copyright © 2014 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objective: This study aims to examine the prevalence and bacteriological findings of different types of intrauterine fluid collection in women presenting with postmenopausal bleeding and the risk factors for predicting positive microbiological culture, mixed growth, and anaerobic growth., Methods: This is a retrospective cohort study. Data from all of the women who were assessed in our one-stop postmenopausal bleeding clinic between 2008 and 2011 and who were found to have intrauterine fluid collection were reviewed. Endometrial aspirates of all women were sent for bacterial culture and histological examination. The risk factors for positive culture were assessed by both univariate and multivariate analyses., Results: A total of 228 cases of intrauterine fluid collection were included for analysis. There were 109 (47.8%) cases of pyometra, 98 (43.0%) cases of hydrometra, and 21 (9.2%) cases of hematometra. Escherichia coli, Bacteroides fragilis, and Enterococcus were the commonest microorganisms isolated from endometrial aspirates. Both endometrial malignancy and benign intrauterine pathologies are not risk factors for positive culture. Advanced age (>75 y) is an independent risk factor for positive culture (odds ratio, 2.89; 95% CI, 1.39-6.01) and mixed growth (odds ratio, 2.18; 95% CI, 1.02-4.67). Residency in nursing homes is an independent risk factor for mixed growth (odds ratio, 2.61; 95% CI, 1.21-5.63) and anaerobic growth (odds ratio, 2.55; 95% CI, 1.01-6.44)., Conclusions: E. coli, B. fragilis, and Enterococcus are the commonest microorganisms isolated from intrauterine fluid. Apart from drainage of the intrauterine fluid collection, successful management also requires appropriate antibiotics and improvement in perineal hygiene.

Background: Misoprostol has become a popular over the counter self-administered abortifacient in Ghana. This study aimed to compare the socio-demographic characteristics and clinical complications associated with misoprostol and non-misoprostol induced abortions among patients admitted to a tertiary public health facility in Ghana., Methods: This was a cross sectional study conducted at the gynaecological ward of Komfo Anokye Teaching Hospital (KATH), over a four-month period using a structured pre-tested questionnaire. Data were analysed using Chi-square, Fisher's exact and student t-tests. Factors associated with severe morbidity were examined using Poisson regression with robust error variance to estimate crude and adjusted relative risks (RRs) with 95% confidence intervals (CIs). P < 0.05 was considered statistically significant., Results: Overall, 126 misoprostol users and 126 misoprostol non-users were recruited into the study. About 71% of the clients had self-induced abortions. Misoprostol users were more likely to be younger (p < 0.001), single (p < 0.001), nulliparous (p = 0.001), of higher educational background (p = 0.001), and unemployed (p < 0.001), than misoprostol non-users. Misoprostol users were more likely than non-users to undergo termination of pregnancy because they wanted to continue schooling (p < 0.001) or were not earning regular income to support a family (p = 0.001). Overall, 182 (72.2%) of the women (79.4% misoprostol users vs. 65.1% misoprostol non-users; p = 0.01) suffered severe morbidity. Nulliparous women (adjusted RR, 1.28; 95% CI, 1.08-1.52) and those who had induced abortion after 12 weeks' gestation (adjusted RR, 1.36; 95% CI, 1.18-1.57) were at increased risks of experiencing severe morbidity. The association between mode of abortion induction and severe morbidity was not statistically significant (p = 0.06)., Conclusion: Self-induced abortions using misoprostol is a common practice among women in this study; nearly three quarters of them suffered severe morbidity. Nonetheless, severe morbidity among misoprostol users and non-users did not differ significantly but was directly related to the gestational age at which the induced abortions occurred. Health education on the dangers of self-induced abortions and appropriate use of medication abortion could help reduce complications associated with induced abortions in Ghana.

Background: Several maternity units in the developing world lack facilities for caesarean section and often have to transfer patients in extremis. This case controlled study aimed to appraise predictive factors for caesarean section., Methods: One hundred and fifty two consecutive women with singleton pregnancies who had caesarean section were studied. The next parturient with normal delivery served as control. Variables such as age, parity, marital status, booking status, past obstetric history, weight, height, infant birth weight were assessed. Data obtained were analysed using SPSS 16.0 Windows package., Results: During the study period, there were 641 deliveries with 257 of them by caesarean section (40.1%).Logistic regression analysis showed that parity, booking status, maternal height; maternal weight, birth weight, previous caesarean section and ante-partum bleeding were significant predictive factors for caesarean section while maternal age was not., Conclusions: These predictive factors should be considered in antenatal counseling to facilitate acceptance by at risk women and early referral.

Background: Cesarean delivery (CD) rates are rising in many parts of the world. To define strategies to reduce them, it is important to identify their clinical and organizational determinants. The objective of this cross-sectional study is to identify sub-types of women at higher risk of CD using demographic, clinical and organizational variables., Methods: All hospital discharge records of women who delivered between 2005 and mid-2010 in the Emilia-Romagna Region of Italy were retrieved and linked with birth certificates. Sociodemographic and clinical information was retrieved from the two data sources. Organizational variables included activity volume (number of births per year), hospital type, and hour and day of delivery. A classification tree analysis was used to identify the variables and the combinations of variables that best discriminated cesarean from vaginal delivery., Results: The classification tree analysis indicated that the most important variables discriminating the sub-groups of women at different risk of cesarean section were: previous cesarean, mal-position/mal-presentation, fetal distress, and abruptio placentae or placenta previa or ante-partum hemorrhage. These variables account for more than 60% of all cesarean deliveries. A sensitivity analysis identified multiparity and fetal weight as additional discriminatory variables., Conclusions: Clinical variables are important predictors of CD. To reduce the CD rate, audit activities should examine in more detail the clinical conditions for which the need of CD is questionable or inappropriate.

Objective: To evaluate the clinicopathological characteristics and the clinical outcome of synchronous malignant neoplasms of the female reproductive tract., Material and Methods: Patients who were operated and diagnosed with synchronous malignant tumor of the genital system (n = 25) at the Dokuz Eylul University Department of Obstetrics and Gynecology Gynecologic Oncology Unit between 1992 and 2012 were included into this study. Recurrent, metastatic and metachronously detected tumors were not included. Age at diagnosis, parity menopausal status, hormone use, presenting sign or symptoms and the clinical outcomes were evaluated., Results: 20 of 25 patients had endometrial-ovarian cancer. The mean age at diagnosis was 53,6 years. The most common presenting symptom was abnormal uterine bleeding. The median follow-up duration for all patients was 69 months. Overall survival for all patients was 87 months and 81 months for patients with endometrial-ovarian cancer 5-year survival rate was 73% for all patients and 68% for patients with endometrial-ovarian cancer., Conclusions: Endometrial-ovarian cancer togetherness is the most common in synchronous gynecologic malignancies. They occur at a younger age and have more favorable prognosis than metastatic primary gynecologic tumors.

Objective: To determine the prevalence of female genital mutilation (FGM), the common forms of FGM, reasons for the practice, associated obstetric outcomes, and how these have affected efforts to achieve Millennium Development Goals (MDGs) 3, 4, and 5 in southeast Nigeria., Methods: A prospective descriptive study of parturients in southeast Nigeria was conducted from January to December 2012. All primigravid women attending delivery services at 2 health institutions during the study period were recruited, examined, and classified using the 2008 WHO classification for FGM., Results: The mean age of the 516 participants was 27.24±4.80 years and most (66.3%) had undergone FGM. Type II FGM was the most common form, accounting for 59.6% of cases. Most FGM procedures were performed in infancy (97.1%) and for cultural reasons (60.8%). Women who had undergone FGM had significantly higher risk for episiotomy, perineal tear, hemorrhage, cesarean delivery, neonatal resuscitation, fresh stillbirth/early neonatal death, and longer hospitalization, with higher risk ratios associated with higher degrees of FGM., Conclusion: FGM is still a common practice in southeast Nigeria, where its association with adverse reproductive outcomes militates against efforts to achieve MDGs 3, 4, and 5., (Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Background: Heavy menstrual bleeding (HMB) and post-menopausal bleeding (PMB) together constitute the commonest gynaecological presentation in secondary care and impose substantial demands on health service resources. Accurate diagnosis is of key importance to realising effective treatment, reducing morbidity and, in the case of PMB, reducing mortality. There are many tests available, including transvaginal scan (TVS), endometrial biopsy (EBx), saline infusion sonography and outpatient hysteroscopy (OPH); however, optimal diagnostic work-up is unclear., Objectives: To determine the most cost-effective diagnostic testing strategy for the diagnosis and treatment of (i) HMB and (ii) PMB., Data Sources: Parameter inputs were derived from systematic quantitative reviews, individual patient data (IPD) from existing data sets and focused searches for specific data. In the absence of data estimates, the consensus view of an expert clinical panel was obtained., Methods: Two clinically informed decision-analytic models were constructed to reflect current service provision for the diagnostic work-up of women presenting with HMB and PMB. The model-based economic evaluation took the form of a cost-effectiveness analysis from the perspective of the NHS in a contemporary, 'one-stop' secondary care clinical setting, where all indicated testing modalities would be available during a single visit., Results: Two potentially cost-effective testing strategies for the initial investigation of women with HMB were identified: OPH alone or in combination with EBx. Although a combination testing strategy of OPH + EBx was marginally more effective, the incremental cost-effectiveness ratio (ICER) was approximately £21,000 to gain one more satisfied patient, whereas for OPH it was just £360 when compared with treatment with the levonorgestrel intrauterine system (LNG-IUS) without investigation. Initial testing with OPH was the most cost-effective testing approach for women wishing to preserve fertility and for women with symptoms refractory to empirical treatment with a LNG-IUS. For the investigation of PMB, selective use of TVS based on historical risk prediction for the diagnostic work-up of women presenting with PMB generated an ICER compared with our reference strategy of 'no initial work-up' of £129,000 per extra woman surviving 5 years. The ICERs for the two other non-dominated testing strategies, combining history and TVS or combining OPH and TVS, were over £2M each., Limitations: In the absence of IPD, estimates of accuracy for test combinations presented some uncertainty where test results were modelled as being discordant., Conclusions: For initial investigation of women presenting to secondary care with HMB who do not require preservation of their fertility, our research suggests a choice between OPH alone or a combination of OPH and EBx. From our investigation, OPH appears to be the optimal first-line diagnostic test used for the investigation of women presenting to secondary care with HMB wishing to preserve their fertility or refractory to previous medical treatment with the LNG-IUS. We would suggest that the current recommendation of basing the initial investigation of women with PMB on the universal TVS measurement of endometrial thickness at a 5-mm threshold may need to be replaced by a strategy of restricting TVS to women with risk factors (e.g. increasing age-raised body mass index, diabetes or nulliparity), obtained from the preceding clinical assessment., Funding: The National Institute for Health Research Health Technology Assessment programme.

Objective: This study evaluated the clinical outcomes and safety of treating caesarean scar pregnancy (CSP) by means of suction curettage followed when required by Foley tamponade, with or without methotrexate (MTX) therapy preceding the curettage., Methods: Twenty-five patients with CSP were identified between August 2008 and April 2012. The first team of doctors treated Group A patients (n = 11) with systemic MTX followed by dilatation and suction curettage whereas the second team of doctors carried out only a suction curettage on women of Group B (n = 14). If uncontrolled vaginal bleeding occurred in either group during or after the operation, a Foley catheter, guided by real time transabdominal ultrasound, was placed in the uterine cavity against the site where the CSP had been implanted., Results: Clinical outcomes in the two groups - including mean estimated blood loss, major complication rate, and hospital length of stay - were comparable. Surgeons used Foley catheter balloons for tamponade in six of the 11 patients in Group A and in seven of the 14 patients in Group B. Treatment was successful in ten of 11 cases in group A and 13 of 14 cases in group B. Group B's mean duration of treatment (2.36 ± 0.49 days) was significantly shorter than that of Group A (14.45 ± 4.96 days; p < 0.001)., Conclusion: Suction curettage, followed when needed by Foley catheter tamponade, is an effective treatment for CSP.

Background: Emergency peripartum hysterectomy (EPH) is an important life saving surgical procedure often necessitated by life threatening obstetric haemorrhage. The indications for peripartum hysterectomy differs between develop and developing countries and may reflect the level of obstetric practice in a region., Patients and Methods: This was a 5-year retrospective study. The medical records of patients who had emergency peripartum hysterectomy at the University of Port Harcourt Teaching Hospital were reviewed and relevant data were retrieved and analyzed., Results: Sixty two cases of peripartum hysterectomy were performed giving a prevalence rate of 0.38% out of 16,113 total deliveries. Being unbooked was significantly associated with peripartum hysterectomy (x2 = 85.29, p = 0.0000). Peripartum hysterectomy was performed for 20.3% of nulliparous women. Subtotal hysterectomy accounted for 55.9% while total hysterectomy was performed for 44.1% of cases. The commonest indication for peripartum hysterectomy was uterine rupture (57.6%). There was no case of ureteric injury Unbooked mothers were 28 times more likely to die than booked mothers. Unbooked status was significantly associated with maternal mortality (p = 0.00008) and perinatal mortality (p = 0.00000)., Conclusion: Emergency peripartum hysterectomy still remains indispensible in obstetric practice in low resource setting. Labour and delivery when well supervised will reduce the need for emergency peripartum hysterectomy. Training of specialist in the skill of internal iliac artery ligation is recommended.

Objective: To examine associations between rheumatoid arthritis (RA) and pregnancy outcomes in first and subsequent births., Design: Cohort study., Setting: Study based on data registered in the Medical Birth Registry of Norway from the period 1 December 1998 to 31 December 2009., Population: Singleton births in women recorded with RA (n = 1496) and reference deliveries from the general population (n = 625,642)., Methods: Outcomes of first and subsequent births were analyzed separately. First birth was defined as the first delivery of nulliparous women. Associations between RA and maternal and perinatal outcomes were assessed in logistic regression analyses and adjusted for maternal age at delivery, gestational age, smoking habits and for previous cesarean section when relevant., Main Outcome Measures: Maternal and perinatal outcomes., Results: Vaginal bleeding was observed more often among women with RA both in first pregnancy [adjusted odds ratio (aOR) 1.8, 95% CI 1.3-2.4] and in subsequent pregnancies (aOR 1.4, 95% CI 1.1-1.9). Elective cesarean section was more common among women with RA both in the first birth (aOR 2.0, 95% CI 1.4-2.8) and in subsequent births (aOR 1.5, 95% CI 1.2-2.0). Preterm delivery was more frequent among women with RA than the reference population in first pregnancy (aOR 1.5, 95% CI 1.1-2.0) and in subsequent pregnancies (aOR 1.5, 95% CI 1.1-1.9)., Conclusion: Complications and poor pregnancy outcomes were more often observed in women with RA and the greatest differences were observed in the first pregnancy., (© 2013 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To estimate the prevalence of and identify factors associated with poor sleep quality and short sleep duration among women with noncancerous gynecologic conditions., Study Design: We conducted a cross-sectional analysis of 838 pre-menopausal women aged 31-54 who enrolled in a study of pelvic problems, hysterectomy and intervention alternatives in 2003/2004. Primary outcomes were poor sleep quality and short sleep duration (six or less hours on average) in the four weeks preceding the interview; hypothesized correlates included sociodemographic characteristics, pelvic problem impact, measured by the Pelvic Problem Impact Questionnaire (PPIQ), and depression, measured by the Patient Health Questionnaire (PHQ)., Results: One-third (33.7%) of the participants reported having poor sleep quality and nearly half (46.8%) reported short sleep duration. In multivariable models, women with major depressive disorder were more likely than those who were not depressed to experience poor sleep quality (adjusted odds ratio (aOR) 4.15, 95% confidence interval (CI) 2.36-7.28, p < 0.001). Women with higher PPIQ scores also were more likely to experience poor sleep quality (aOR 1.59, 95% CI 1.27-1.98, p < 0.001) and short sleep duration (aOR 1.37, 95% CI 1.11-1.69, p < 0.003). Finally, women who self-identified as African-American (aOR 2.81, 95% CI 1.83-4.32, p < 0.001) or Asian/Pacific Islander (aOR 2.32, 95% CI 1.32-4.09, p < 0.003) were more likely than White women to have short sleep duration., Conclusions: Sleep problems are prevalent among women with noncancerous gynecologic conditions, and are associated with depression and high pelvic problem impact. Providers should be proactive in inquiring about and offering solutions for sleep difficulties experienced by their patients.

Objective: To examine the clinicopathological characteristics of pregnant women who presented with intermittent hemorrhage occurring throughout pregnancy until delivery., Method: A total of 24 women with intermittent hemorrhage occurring throughout pregnancy were categorized into two groups, a group with persistent subchorionic hematoma (PSH) and another with chronic abruption (CA), and the pregnancy outcomes were compared between the two groups. The data were expressed as medians (range)., Results: There were 18 women in the PSH group and 6 women in the CA group. The median gestational age at delivery was 27.9 (22.1-33.4) weeks in the PSH group and 32.9 (24.3-33.1) weeks in the CA group, revealing a significantly earlier gestational age at delivery in the former group (p = 0.014). The percentage of the women developing acute abruption tended to be higher in the CA group [66.7 % (4/6)] than in the PSH group [26.3 % (5/18)]. Small for gestational age (SGA) infants and neonatal chronic lung disease were seen at high incidences, but only in the PSH group [21.1 % (4/18) and 42.1 % (8/18), respectively]., Conclusion: PSH was associated with earlier gestational age at delivery, a higher incidence of SGA infants, and poorer pregnancy outcomes than CA.

Objective: To determine whether termination of pregnancy (TOP), including the method used or gestational age at termination, affects future obstetric and perinatal outcomes., Design: Register-based cohort., Setting: Aberdeen Maternity Hospital, Scotland, UK., Population: From the Aberdeen Maternity and Neonatal Databank (AMND) we identified 3186 women who had terminated their first pregnancy and then had a second pregnancy of beyond 24 weeks of gestation between 1986 and 2010. We identified 42,446 women who had their first delivery in the same time period, for comparison., Methods: Univariate and multivariate logistic regression was used to compare outcomes between groups. Complete case analysis with adjustment of confounding factors was carried out, and adjusted odds ratios (aORs) with 99% confidence intervals are presented., Main Outcome Measures: The primary outcome was spontaneous preterm delivery (SPTD)., Results: No statistically significant association was found between TOP in the first pregnancy and SPTD in the next pregnancy (aOR 1.05; 99% CI 0.83-1.32). Neither medical (aOR 1.03; 99% CI 0.72-1.46) nor surgical (aOR 1.06; 99% CI 0.78-1.44) termination appeared to affect the risk of spontaneous preterm delivery in the subsequent pregnancy. Late termination (≥13 weeks of gestation) did not appear to increase the risk of spontaneous preterm delivery compared with early termination (<13 weeks of gestation) (aOR 1.65; 99% CI 0.94-2.92), nor compared with primigravid women (aOR 1.25; 99% CI 0.97-1.62). There was an associated increased risk of antepartum haemorrhage in the next pregnancy following TOP (P < 0.01; aOR 1.26; 99% CI 1.10-1.45)., Conclusions: Evidence on obstetric and perinatal outcomes following TOP remains conflicting. This study suggests that TOP is not associated with an increased risk of spontaneous preterm delivery. Neither the method nor the gestational age of TOP has any effect on this lack of association., (© 2013 Royal College of Obstetricians and Gynaecologists.)

Background and Objectives: Our aim was to evaluate whether the use of barbed suture for vaginal cuff closure is associated with a decrease in postoperative vaginal bleeding compared with cuff closure with polyglactin 910 in patients who have undergone laparoscopic hysterectomy., Methods: We performed a cohort study of patients who underwent laparoscopic hysterectomy between January 2008 and July 2012 by the minimally invasive gynecologic surgery division of the Gynecology, Obstetrics and Human Reproduction Department at Fundación Santa Fe de Bogotá University Hospital, Bogotá, Colombia., Results: A total of 232 women were studied: 163 were in the polyglactin 910 group, and 69 were in the barbed suture group. The main outcome, postoperative vaginal bleeding, was documented in 53 cases (32.5%) in the polyglactin 910 group and in 13 cases (18.8%) in the barbed suture group (relative risk, 0.57; 95% confidence interval, 0.34-0.9; P = .03). No statistically significant differences were found in other postoperative outcomes, such as emergency department admission, vaginal cuff dehiscence, infectious complications, and the presence of granulation tissue., Conclusion: In this study an inverse association was observed between the use of barbed suture for vaginal cuff closure during laparoscopic hysterectomy and the presence of postoperative vaginal bleeding.

Objective: Hysteroscopic endometrial resection or destruction in the indication of abnormal uterine bleeding or post-menopausal bleeding represents an alternative to hysterectomy, as it carries a lower morbidity rate. In case of failure of such procedure though, hysterectomy will most often be proposed as a second line of treatment. The place of the repetition of an endometrial destruction procedure has not yet been evaluated. The aim of our study is to evaluate the efficiency and the satisfaction after two consecutive techniques of endometrial destruction in case of abnormal uterine bleeding or post-menopausal bleeding., Material and Methods: Nineteen patients presenting with recurring abnormal uterine bleeding after one procedure of endometrial destruction, underwent in our department, between 2004 and 2011, a second conservative endometrial procedure., Results: No complication occurred during the repeated procedure. Sixteen of the nineteen patients (84.2 %) included answered a questionnaire. The mean delay since the second procedure was 27 months [25; 29]. Eight patients (i.e. 50 %) later underwent a hysterectomy, with 5 of them (31.25 % of all 16 patients) being directly attributed to treatment failure. Patients said to be satisfied with the management of their condition in 68.75 % of cases, and 93.75 % of them would recommend it to a friend., Conclusion: Our results suggest that a second conservative management in case of recurrence of AUB is effective. Hysterectomy could be avoided in 50 % of cases. A second conservative treatment could be an interesting option for patients with medical contra-indication for heavier surgery, as well as for patients willing to keep their uterus., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objective: To explore the risk of adverse maternal and perinatal outcomes in women with antepartum bleeding of unknown origin (ABUO)., Design: Cohort study based on data extracted from the Aberdeen Maternity and Neonatal Databank. Exposure was antepartum haemorrhage occurring after the first trimester not attributable to placenta praevia or placental abruption., Setting: Aberdeen Maternity Hospital, Aberdeen, Scotland, UK., Population: All primigravidae delivering between 1976 and 2010., Methods: Data were analysed using univariate and multivariate statistical methods., Main Outcome Measures: Pre-eclampsia, induced labour, mode of delivery, preterm delivery, postpartum haemorrhage, admission to neonatal unit, perinatal death., Results: Between 1976 and 2010, there were 7517 women with ABUO and 68,423 women without ABUO in the cohort. Women with ABUO were more likely to be non-smokers, belong to a lower social class, and have a higher body mass index. ABUO was a significant risk factor for induced labour (adjusted odds ratio, aOR, 1.23; 95% CI 1.16-1.31), preterm delivery at <37 weeks of gestation (aOR 2.30; 95% CI 2.11-2.50), and postpartum haemorrhage (aOR 1.15; 95% CI 1.06-1.25). There was no significant association detected with pre-eclampsia (aOR 0.93; 95% CI 0.83-1.05). Whereas there was an increased risk of low birthweight (aOR 0.90; 95% CI 0.79-1.03) and stillbirth (aOR 0.92; 95% CI 0.66-1.30) with ABUO on univariate analysis, once adjusted for confounding factors this risk was non-significant., Conclusion: Pregnancies complicated by ABUO are at a greater risk of preterm delivery and induced labour. There was no increase seen in perinatal mortality after adjusting for preterm birth., (© 2013 Royal College of Obstetricians and Gynaecologists.)

Objective: To develop and test a risk-scoring model for the prediction of endometrial cancer among symptomatic postmenopausal women at risk of intrauterine malignancy., Methods: We prospectively studied 624 postmenopausal women with vaginal bleeding and endometrial thickness > 4 mm undergoing diagnostic hysteroscopy. Patient characteristics and endometrial assessment of women with or without endometrial cancer were compared. Then, a risk-scoring model, including the best predictors of endometrial cancer, was tested. Univariate, multivariate, and ROC curve analysis were performed. Finally, a split-sampling internal validation was also performed., Results: The best predictors of endometrial cancer were recurrent vaginal bleeding (odds ratio (OR) = 2.96), the presence of hypertension (OR = 2.01) endometrial thickness > 8 mm (OR = 1.31), and age > 65 years (OR = 1.11). These variables were used to create a risk-scoring model (RHEA risk-model) for the prediction of intrauterine malignancy, with an area under the curve of 0.878 (95% CI 0.842 to 0.908; P < 0.0001). At the best cut-off value (score ≥ 4), sensitivity and specificity were 87.5% and 80.1%, respectively., Conclusion: Among symptomatic postmenopausal women with endometrial thickness > 4 mm, a risk-scoring model including patient characteristics and endometrial thickness showed a moderate diagnostic accuracy in discriminating women with or without endometrial cancer. Based on this model, a decision algorithm was developed for the management of such a population.

Objective: To determine risk factors associated with massive uterine bleeding during dilation and suction curettage (D&C) after uterine artery embolization (UAE) for the treatment of cesarean scar pregnancy (CSP)., Methods: Data from 128 CSP patients treated with D&C after UAE were analyzed to assess risk factors associated with massive uterine bleeding (blood loss 500mL or more) during D&C after UAE., Results: In total, 15 CSP patients had massive bleeding during D&C after UAE. Univariate analysis showed that a greater gestational age (GA), a larger CSP mass size, a thinner myometrium at the implantation site, a GA of 8weeks or more, a CSP mass diameter of 6cm or more, and evidence of fetal heartbeat were risk factors for massive bleeding (P<0.05). In a binary logistic regression analysis, GA of 8weeks or more and CSP mass diameter of 6cm or more remained as the only significant risk factors for massive bleeding (OR 11.49 [95% CI 1.08-122.13] and OR 96.59 [95% CI 6.20-150.57], respectively; P<0.05)., Conclusion: For CSP masses with a GA of 8weeks or more and a diameter of 6cm or more, the outcome of surgical evacuation after UAE tends to be unsatisfactory., (© 2013.)

Abnormal peri-menopausal bleeding is a common clinical problem. Decisions to investigate if the menstrual disorders are related to an underlying pathology or represent physiologic changes are often complex especially as no clear guidance is available. The aim of this review is to present a summary of the current available evidence regarding the investigation tools used to evaluate women with abnormal uterine bleeding during menopausal transition and in the post-menopausal period. In this article, we focus mainly on the investigation and exclusion of endometrial carcinoma, as this represents the most common malignancy diagnosed.

Objectives: the aim of this retrospective study was to assess if a first trimester subchorionic hematoma (SCH) influences the pregnancy outcome and whether pv bleeding can be a prognostic factor for the pregnancy course., Material and Methods: the study included 185 pregnant women hospitalized due to symptoms of a threatening miscarriage. Patients were divided into 2 groups: 119 women with SCH (study group) and 66 patients with normal prenatal scan (control group), further subdivided into cases with and without pv bleeding, irrespectively of the outcome of the ultrasound scan. Obstetric and neonatal data were analyzed., Results: 1. A pregnancy complicated by SCH is more often associated with a poor outcome -- 23.78% of the study group patients had a miscarriage versus 7.62% of the controls. 2. Pregnancy with SCH is more likely to be lost before 9 weeks of gestation. 3. The "N" ratio, that expresses the maximal length of the hematoma to the maximal length of the fetus, equal to 2.5 or more, is associated with a risk of miscarriage. 4. The surface area of SCH equal to 280mm(2) or more is more likely to reveal with vaginal bleeding. 5. Vaginal bleeding can be a prognostic factor for the mode of delivery -- a higher rate of the Cesarean section is observed in patients with pv bleeding. 6. SCH is a complication that occurs in older women, with the limit of 30 years of age. 7. In this study there were no significant correlations between subchorionic hematoma or pv bleeding and PTL, IUGR, PIH, abnormal volume of the amniotic fluid, parity and order of gestation and delivery, Conclusions: subchorionic hematoma can be associated with poor pregnancy outcome and the "N" index may be a useful predictor of the further course of a pregnancy Pv bleeding may be a prognostic factor for the delivery mode.

Objective: To evaluate the prevalence of first trimester vaginal bleeding among patients with abnormal second and third trimester uterine artery Doppler., Methods: A prospective study of patients with a uterine artery Doppler measurement between 27 and 42 weeks' gestation was undertaken. A comparison was made between two groups: patients with and without first trimester vaginal bleeding. Abnormal uterine artery Doppler was defined as PI >95th% or the presence of a diastolic notch., Results: Of the 277 patients that were included in the study, 65 (23%) had first trimester vaginal bleeding. No differences were noted in uterine artery Doppler waveforms among patients with and without first trimester vaginal bleeding. Among patients with first trimester vaginal bleeding, 9 (14%) had a bilateral uterine artery notch and 56 (86%) did not, compared with 51 (24%) and 161 (76%), in the control group, respectively. Patients with first trimester vaginal bleeding, and a bilateral uterine artery notch had significantly higher rates of small for gestational age neonates, low-Apgar scores (<7) at one minute and cesarean deliveries compared to patients with first trimester vaginal bleeding who did not have bilateral uterine artery notch., Conclusion: First trimester vaginal bleeding was not associated with a higher incidence of abnormal uterine artery waveforms or with placental related conditions. However, adverse perinatal outcomes were found when first trimester vaginal bleeding was associated with second and third trimester bilateral uterine artery notchs.

Background: Traditionally, research on abnormal uterine bleeding (AUB) focused on measured menstrual blood loss. However, the main burden of this symptom from the patient perspective is its impact on quality of life. Better describing the demographic characteristics, quality of life, and utilization of medical care of women with AUB could assist with health resource planning for this population., Methods: We analyzed data from the Medical Expenditures Panel Survey from 2002 to 2010. AUB was identified by International Classification of Diseases, ninth edition (ICD-9) code group 626, disorders of menstruation and other abnormal bleeding from the female genital tract. Health-related quality of life was assessed by the Short-form 12 Health Survey (SF-12, QualityMetric) physical and mental component summary scores (PCS and MCS). Poorer health-related quality of life was defined as PCS or MCS <50. Odds ratios (OR) and 95% confidence intervals (CI) for the association of AUB with poorer SF-12 scores and having a usual source of care were estimated by multivariable logistic regression models., Results: Data analyzed represented an annual average of 56.2 million nonpregnant women between ages 18 and 50 years. We estimate that 1.4 million women per year (95% CI: 1.3-1.5 million) reported AUB. Women with AUB were more likely to be younger, Caucasian, and obese than women without AUB. Compared to women without AUB, women with AUB had greater odds of a poorer PCS score (OR=1.30, 95% CI: 1.10-1.55), a poorer MCS score (OR=1.28, 95% CI: 1.10-1.51), and a usual source of care (OR=1.85, 95% CI: 1.44-2.38)., Conclusions: AUB is associated with diminished physical and mental health status and having a usual source of medical care.

Objective: To obtain estimates of the rates of occurrence and spontaneous resolution of intermenstrual and postcoital bleeding, and investigate any association with underlying malignancy., Design: Two-year prospective cohort study with medical record review during the survey period, and for the subsequent 2 years., Setting: Seven general practices with 67 100 registered patients., Population: All women aged 40-54 years on the practices age-sex registers., Methods: Baseline postal questionnaire, with follow-up questionnaires sent to naturally menstruating respondents at 6, 12, 18 and 24 months. Medical record review using computerised searches from baseline to 48 months., Main Outcome Measures: Prevalence and incidence of intermenstrual and postcoital bleeding, and rate of spontaneous resolution., Results: A total of 7121 baseline questionnaires were sent out, with an initial response rate of 66%. A total of 2104 naturally menstruating women were recruited for the prospective cohort study. The 2-year cumulative incidence of intermenstrual bleeding was 24% (95% CI 21-27%), and that of postcoital bleeding was 7.7% (95% CI 6.2-9.5%). The rates of spontaneous resolution without recurrence for 2 years were 37% (95% CI 29-45) and 51% (95% CI 40-62), respectively. Of the 785 women identified with intermenstrual and/or postcoital bleeding, only one developed uterine cancer., Conclusion: There is a high prevalence, incidence, and spontaneous rate of resolution of intermenstrual and postcoital bleeding in naturally menstruating women during the perimenopausal years. The association of these symptoms with malignancy is weak. This is of importance to women in deciding when to consult and to those devising public health campaigns concerning symptoms of possible oncological significance., (© 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.)

Background: Postabortion insertion of intrauterine contraception has the potential to decrease unintended pregnancy and repeat abortions, but little is known about how to ensure that women receive appropriate counseling about this method in this setting. The goal of this investigation was to document women's questions and to assess retention of information provided during contraceptive counseling after immediate postabortion intrauterine contraceptive placement., Study Design: Women who received postabortion intrauterine contraceptives (IUCs) at an urban, hospital-based abortion clinic were surveyed 2-3 months postabortion to evaluate for expulsion, assess their concerns about IUC and evaluate retention of information provided during contraceptive counseling., Results: Of 141 women contacted, 121 participated. Almost half of participants (46%) had responses to the question "Do you have any questions or concerns about your intrauterine device?" that fell into the following categories: spotting/bleeding (16%), cramping/pain (15%), string management (10%), expulsion concern (5%). Seventy percent reported less bleeding during menses than prior to IUC placement, and 37% had less cramping. Sixty-three percent were able to accurately report statistics regarding IUC efficacy, 56% recalled common side effects, and 42% remembered what to do if expulsion occurred., Conclusion: Although IUCs are highly effective and their placement in the abortion setting is safe, women frequently have questions and do not recall critical counseling information about IUCs. In order to improve IUC continuation, techniques to improve both patient knowledge retention and anticipatory guidance should be studied further., (Copyright © 2013. Published by Elsevier Inc.)

Objective: To investigate abortion practices of Nepali women requiring postabortion care., Design: Cross-sectional study., Setting: Four tertiary-care hospitals in urban and rural Nepal., Sample: A total of 527 women presenting with complications from induced abortion in 2010., Methods: Women completed questionnaires on their awareness of the legal status of abortion and their abortion-seeking experiences. The method of induction and whether the abortion was obtained from an uncertified source was documented. Multivariable logistic regression was used to identify associated factors., Main Outcome Measures: Induction method; uncertified abortion source., Results: In all, 234 (44%) women were aware that abortion was legal in Nepal. Medically induced abortion was used by 359 (68%) women and, of these, 343 (89%) took unsafe, ineffective or unknown substances. Compared with women undergoing surgical abortion, women who had medical abortion were more likely to have obtained information from pharmacists (161/359, 45% versus 11/168, 7%, adjusted odds ratio [aOR] 8.1, 95% confidence interval 4.1-16.0) and to have informed no one about the abortion (28/359, 8% versus 3/168, 2%, aOR 5.5, 95% CI 1.1-26.9). Overall, 291 (81%) medical abortions and 50 (30%) surgical abortions were obtained from uncertified sources; these women were less likely to know that abortion was legal (122/341, 36% versus 112/186, 60%, aOR 0.4, 95% CI 0.2-0.7) and more likely to choose a method because it was available nearby (209/341, 61% versus 62/186, 33%, aOR 2.5, 95% CI 1.5-4.3), compared with women accessing certified sources., Conclusions: Among women presenting to hospitals in Nepal with complications following induced abortion of pregnancy, the majority had undergone medically induced abortions using unknown substances acquired from uncertified sources. Women using medications and those accessing uncertified providers were less aware that abortion is now legal in Nepal. These findings highlight the need for continued improvements in the provision and awareness of abortion services in Nepal., (© 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.)

Objectives: To investigate the long-term endometrial safety and bleeding pattern of the 0.25 mg drospirenone/0.5 mg 17β-estradiol (DRSP/E2) dose combination compared with 0.5 mg norethisterone acetate (NETA)/1.0 mg E2, in postmenopausal women., Methods: A total of 662 postmenopausal women aged between 40 and 65 years with an indication for hormone therapy verified by the investigator were randomized to participate in this 1-year, double-blind, active comparator-controlled study. The primary efficacy variable was the proportion of women with an endometrial biopsy assessment of 'hyperplasia or worse' at any time during or after 13 cycles of treatment., Results: No evaluable women in the DRSP/E2 or NETA/E2 groups had an endometrial biopsy result of 'hyperplasia or worse'. The incidence of amenorrhea was higher in the DRSP/E2 group than the NETA/E2 group during months 1-3 (69.0% vs. 56.0%), with comparable amenorrhea rates of approximately 80% during months 10-12. Improvements in menopausal symptoms (exploratory efficacy variables) were similar in the two groups, while there were fewer women with treatment-related adverse events (18.4% vs. 25.6%) or adverse events leading to discontinuation of study drug (8.4% vs. 15.1%) in the DRSP/E2 group than the NETA/E2 group. There were no treatment-related thromboembolic or cardiovascular events in the DRSP/E2 group vs. two events in the NETA/E2 group., Conclusions: The low-dose, 0.25 mg DRSP/0.5 mg E2 dose combination met the criteria for endometrial safety and demonstrated a favorable risk/benefit profile in this 1-year, double-blind, randomized study of postmenopausal women.

Background: Diagnostic hysteroscopy is an endoscopic technique that allows the evaluation of the endocervical canal and uterine cavity., Objective: To evaluate indications, complications and referral to operative hysteroscopy. To analyze the correlation between sonographic display, hysteroscopy findings and histological diagnosis., Materials and Methods: Retrospective and descriptive study of 904 patients who underwent diagnostic hysteroscopy between January 1, 2008 and June 30, 2012., Results: The most frequent indication was sonographic detection of endometrial polyps (75% were premenopausal and 71.2% postmenopausal). The complication rate associated with the test was 11.4%. The reduction experimented in operative hysteroscopies was from 31.2% in 2008 to 12.2% between January and June 2012. When a polyp or a myoma was detected by sonography, diagnostic hysteroscopy showed them in 64.4% y 62.5% of the cases, respectively. The correlation between hysteroscopic findings and histopathologic diagnosis was 77.7% for normal endometrium, 77.9% for polyps, 17.8% for hyperplasic appearance and 100% for carcinoma suspicion., Conclusions: Diagnostic hysteroscopy is a safe technique that allows small interventions avoiding operative hysteroscopies. There is a good relation between hysteroscopic visual inspection and anatomopathologic diagnosis, but biopsy should be taken except if normal endometrium is visualized.

Objective: To identify possible predictive factors associated with emergent delivery of antenatally diagnosed placenta accreta and to estimate association between emergent delivery and adverse maternal outcomes in comparison to elective delivery., Methods: A retrospective study of all patients with placenta accreta diagnosed antenatally and confirmed pathologically, who were delivered between 2000 and 2010. Baseline characteristics and outcomes of emergent deliveries were compared with elective deliveries., Results: A total of 48 women met inclusion criteria, of which 24 (50%) were delivered emergently. 79.2% of emergent deliveries were preceded by antenatal bleeding (p = 0.0005), and 62.5% were preceded by recurrent bleeding (p = 0.001). Comparison of elective and emergent deliveries revealed no clinical significant difference in maternal outcome., Conclusions: Antenatal bleeding is associated with an increased risk of emergent delivery. Emergent delivery in a tertiary care facility with immediate access to blood bank and ICU capabilities does not appear to be associated with an increased risk of adverse maternal outcomes. Consequently, some patients may be candidates for delivery later than 34 weeks of gestation.

Objectives: To determine whether the California Maternal Quality Care Collaborative risk groups predicted the risk of peripartum hemorrhage and to determine which women should have peripartum pretransfusion testing performed., Methods: Over a 1-year period, 10,134 women who delivered at a single hospital were included in this retrospective cohort study. The majority of the California Maternal Quality Care Collaborative risk factors were assessed retrospectively. Each mother was assigned to one of the three peripartum hemorrhage risk groups according to the guidelines. The individual peripartum hemorrhage risk factors and the three risk groups correlated with the occurrence of a significant peripartum hemorrhage (a hemorrhage requiring transfusion of 1 unit or more of red blood cells). Other risk factors for peripartum hemorrhage were assessed and a modified high-risk category was created., Results: The incidence of a significant peripartum hemorrhage within each group was as follows: low (0.8%); medium (2.0%); and high (7.3%). High included an increase that was statistically significant (P<.001). All of the assessed California Maternal Quality Care Collaborative risk criteria were significantly associated with an increased peripartum hemorrhage rate (P≤.02) except macrosomnia and morbid obesity. Other risk factors not included in the California Maternal Quality Care Collaborative criteria (preterm delivery, uterine rupture, hypertension, previous cesarean delivery, and a model of accreta or percreta) also correlated with peripartum hemorrhage. This modified risk group included 85% of those women with significant hemorrhage; however, 45% of women were included and only 2.6% of this modified group hemorrhaged., Conclusion: The California Maternal Quality Care Collaborative risk stratification showed an increasing risk for transfusion as the risk grade increased. Women in the California Maternal Quality Care Collaborative high-risk group (or as determined by their providers) should have pretransfusion testing performed., Level of Evidence: II.

Study Objective: To compare the occurrence of vaginal bleeding and patient satisfaction 12 months after laparoscopic supracervical hysterectomy performed with and without excision of the endocervix., Design: A prospective, randomized, controlled trial., Design Classification: Canadian Task Force Classification I., Setting: Norwegian university teaching hospital., Patients: One hundred forty consecutive premenopausal women referred for hysterectomy on the basis of a benign condition., Interventions: The study participants were randomized to standard laparoscopic supracervical hysterectomy (n = 70) or laparoscopic supracervical hysterectomy with excision of the endocervix in a reverse cone pattern (n = 70)., Measurements and Main Results: The main outcome measures were the occurrence of vaginal bleeding and patient satisfaction 12 months after the procedure. One hundred thirty women (92.3%) were followed up according to the study protocol. In total, 43 women (33.1%) reported bleeding episodes during the first 12 months after the laparoscopic supracervical hysterectomy; 22 (16.9 %) of these women had cyclic bleeding. All reported bleeding episodes were minimal. Patient satisfaction after the hysterectomy was very high with a mean visual analog score (on a scale of 0-10) of 9.3 (standard deviation = 1.4). There were no significant differences between the 2 treatment groups regarding the main outcomes 12 months after the procedure., Conclusion: The patient satisfaction after laparoscopic supracervical hysterectomy is very high. Episodes of minimal vaginal bleeding after the procedure are relatively common, but such bleeding does not affect patient satisfaction. Removal of the endocervix by reverse conization during laparoscopic supracervical hysterectomy appears to have no effect in terms of reduced bleeding or improved patient satisfaction., (Copyright © 2013 AAGL. Published by Elsevier Inc. All rights reserved.)

This study assessed the risk for maternal complications in women and neonatal outcomes in children conceived following assisted reproductive treatment as compared with spontaneously conception and also separately evaluated conventional IVF and intracytoplasmic sperm injection (ICSI). The prospective cohort included 1161 women with singleton pregnancies: 561 who conceived following assisted reproduction (223 following IVF and 338 following ICSI) and 600 who conceived spontaneously. No differences were observed in pregnancy complications (including spontaneous abortion, pregnancy-induced hypertension, gestational diabetes and Caesarean delivery) except for significantly increased risk for excess vaginal bleeding in assisted reproduction pregnancies (21.4% versus 12.9%; OR 1.67, 95% CI 1.18-2.37), which was prominent in women who reported polycystic ovary syndrome. Neonates born following assisted reproduction had increased risk for prematurity (10.6% versus 5.3%; OR 1.72, 95% CI 1.04-2.87), and IVF, but not ICSI, was associated with significantly increased risk for prematurity (OR 2.36, 95% CI 1.28-4.37) and low birthweight (OR 1.89, 95% CI 1.03-3.46). In conclusion, this study observed only an increased risk for excess vaginal bleeding as a pregnancy-associated complication in singleton pregnancies following assisted compared with spontaneous conception. However, singleton neonates born following IVF, but not ICSI, were at increased risk for prematurity., (Copyright © 2013 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)