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Does endometriosis have an effect on the placental histopathology pattern and perinatal outcome in singleton live births resulting from IVF treatment?Retrospective cohort study evaluating the data on all live births following IVF treatment between 2009 and 2017 at one university-affiliated tertiary hospital. All patients had placentas sent for full gross and histopathology assessment, irrespective of complication status or delivery mode. The primary outcomes of the study included anatomical, inflammation, vascular malperfusion and villous maturation placental disorders. The secondary outcomes included fetal, maternal, perinatal and delivery complications. A multivariate logistic model was used to adjust the results for confounding factors potentially associated with significant placental characteristics.A total of 1057 live births were included in the final analysis and were allocated to the group of women with endometriosis (n = 75) and those without (n = 982). After adjustment for confounding factors, endometriosis was found to be significantly associated with acute chorioamnionitis with moderate to severe maternal (odds ratio [OR] 2.2, 95% confidence interval [95% CI] 1.1-4.6) and fetal (OR 4.9, 95% CI 1.8-13.1) inflammatory response, placenta previa (OR 3.1, 95% CI 1.2-7.8), subchorionic fibrin deposition (OR 3.4, 95% CI 1.2-9.1), intervillous thrombosis (OR 3.4, 95% CI 1.5-8.1), and fetal vascular malperfusion (OR 5.1, 95% CI 1.4-18.1), as well as with preterm birth (OR 2.5, 95% CI 1.4-4.7).Endometriosis has a significant impact on the placental histopathology and is associated with a higher incidence of preterm birth.

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

We aimed at studying isolated Fallopian tube torsion (IFTT) in a relatively large cohort of women and to evaluate different features of IFTT in comparison to a large cohort of women with non-IFTT adnexal torsion (NIAT). This was a retrospective cohort study. We included women with surgically confirmed ovarian and/or Fallopian tube torsion between March 2011 and June 2020. Fifty-four cases of IFTT were surgically confirmed during the study period and were compared to 422 surgically confirmed NIAT. The rate of controlled ovarian hyperstimulation treatments, current pregnancy, and vomiting was lower in the IFTT group compared with the NIAT group. Cervical tenderness and vaginal discharge were more common in the IFTT group. Oedematous and enlarged ovaries were less common in the IFTT group. In multivariate regression analysis, the following factors were independently associated with IFTT: (i) vaginal discharge [adjusted odds ratio (aOR) 95% CI 8.16, 1.98-33.55]; (ii) cervical motion tenderness (aOR 95% CI 2.71, 1.01-7.29); (iii) fertility treatments (aOR 95% CI 0.26, 0.70-0.77); (iv) previous abdominal surgery (aOR 95% CI 0.46, 0.22-0.96); (v) vomiting (aOR 95% CI 0.38, 0.19-0.76); and (vi) enlarged ovary (aOR 95% CI 0.34, 0.18-0.65). In conclusion, we have identified factors positively and negatively associated with IFTT in a large cohort of women with adnexal torsion.

The aim of this study was to compare office to conventional operative hysteroscopy for the treatment of retained products of conception (RPOC). This retrospective cohort study included all women who underwent hysteroscopy due to RPOC between January 2018 and December 2019, in a single tertiary medical care center. Exclusion criteria for hysteroscopy included the following: (1) proximity to delivery (up to 3 weeks); (2) hemodynamic instability; (3) active massive bleeding; and (4) genital tract infection. See-and-treat hysteroscopy (study group) outcomes were compared to operative hysteroscopy (controls). Data were collected from women's medical records. Primary outcome was defined as successful removal of all suspected RPOC with no need for additional intervention. Data are presented as median and interquartile range. During the study period, 222 women underwent hysteroscopy due to RPOC. Of them, 138 (62%) and 84 (38%) underwent see-and-treat and operative hysteroscopy, respectively. Symptomatic women were more commonly referred to operative hysteroscopy (60 (71%) vs. 54 (39%); p = 0.001). Maximal diameter of the suspected finding was smaller both by ultrasound examination (13 (10-18) vs. 18 (13-32) mm; p = 0.001) and by surgeon estimation during diagnostic hysteroscopy (12 (8-20) vs. 20 (14-30) mm; p = 0.001), in the see-and-treat compared to the operative hysteroscopy group, respectively. While comparing success rate between groups, no difference was observed. Sub-analysis by the maximal diameter of RPOC findings revealed that see-and-treat success rate is reduced as the RPOC is larger. Success rate was high and comparable to operative hysteroscopy for findings ≤ 2 cm (102/117 (87%) vs. 49/54 (91%); p = 0.79). Nevertheless, for RPOC 2 cm, success was significantly more frequent in the operative hysteroscopy group (28/30 (93%) vs. 9/16 (57%); p = 0.002). This finding was supported by logistic regression analysis that found maximal diameter of RPOC as the only parameter associated with success rate (B = 0.96; p = 0.03). Office operative hysteroscopy is a feasible treatment option for the removal of RPOC when maximal diameter is taken under consideration due to its association to success rate.Clinical trial registration: The study protocol was approved by the "Sheba Medical Center" Review Board (ID 5200-18 SMC) on June 24, 2018.

To develop a simple predictive model for pre-operative diagnosis of adnexal torsion (AT).A retrospective cohort study with a retrospective validation, including 669 separate episodes of women who underwent laparoscopy due to a suspected AT between January 2011 and June 2020. We compared the pre-operative characteristics between women with surgically confirmed AT and those without.The derivation cohort included 615 episodes of suspected AT. AT was surgically confirmed in 445 episodes (72%). The retrospectively collected validation cohort included 54 episodes, with 31 (57.4%) surgically confirmed AT. In a multivariate regression analysis, vomiting, neutrophils to lymphocytes ratio 3.5 and sonographic finding of enlarged ovary were independently associated with AT [OR 95% CI 2.78 (1.21-6.36), 3.15 (1.42-6.97) and 2.80 (1.33-5.88), respectively]. In the derivation cohort, the PPV for AT diagnosis was 69.7%, 84.5% and 93.1% if 1, 2 and 3 risk factors were present, respectively. Retrospective validation analysis underlined a PPV of 67.6%, 82.6 and 66.6% for 1, 2 and 3 risk factors, respectively.We have developed and validated a simple predictive model for pre-operative diagnosis of AT, based on three parameters. Our model may assist clinicians while evaluating patients with suspected AT and improve pre-operative diagnosis.

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.

What is the outcome of fertility-preservation treatments in women with endometrioma, especially those with endometrioma larger than 4 cm?Retrospective cohort study. Women with definitive diagnosis of ovarian endometriosis (by histology or ultrasound), who underwent fertility-preservation treatment in two IVF units between 2016 and 2021, were included. As some women cryopreserved oocytes and other embryos, the primary outcome was the number of metaphase II (MII) oocytes retrieved.Seventy-one women with ovarian endometriosis (OMA) underwent 138 fertility-preservation cycles. The median age of patients was 31 years. Forty out of 71 (56%) women underwent at least one surgery for OMA before fertility-preservation treatment. Multivariate analysis of each patient's first cycle was used. Women who underwent OMA surgery before fertility-preservation treatment had a 51.7% reduction (95% CI 26.1 to 68.5, P = 0.001) in the number of MII oocytes compared with women with OMA who did not undergo surgery. Among a subgroup who did not undergo surgery, those with an endometrioma larger than 4 cm had similar anti-Müllerian hormone concentration (2.6 ng/ml versus 2.1 ng/ml), number of oocytes retrieved (9 versus 9) and number of MII oocytes (7.6 versus seven 7) compared with women with an endometrioma of 4 cm or less.Discussing fertility-preservation treatment options with patients with OMA is recommended, especially if surgery is planned.

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.

Background: The use of cervical cerclage in singleton gestations is a well-established method to prevent preterm birth. Although cervical cerclage is becoming more frequently used among twin pregnancies, it is still a matter of great controversy. The purpose of this study was to compare the safety and efficacy of physical examination- and ultrasound-indicated cervical cerclage in twin versus singleton gestations.Methods: A retrospective cohort study of all ultrasound (cervical length ≤25 mm) and physical examination indicated cerclage cases performed over a 9-year period. The primary outcome was the time interval from cerclage placement to delivery. Results: The study cohort included 100 singleton and 16 twin pregnancies. Time interval from cerclage placement to delivery was comparable in twin and singleton gestations (14.1 versus 16.3 weeks, p=0.11), as well as the rates of preterm births 24 weeks was lower in the twin group (62% versus 89%, p=0.045). Regression analysis identified that cervical dilation, but not twin gestation, was the only factor independently associated with increased risk for birth before 32 weeks.Conclusion: Ultrasound-indicated and physical examination-indicated cerclage in twin and singleton gestations have comparable efficacy.

Both expectant and interventional managements are acceptable in selected cases, when heterotopic pregnancy is diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.Heterotopic pregnancy, though relatively rare, is potentially a life-threatening condition. The aim of the study is to compare expectant versus interventional management of heterotopic pregnancies.This is a retrospective cohort study including all women diagnosed with heterotopic pregnancy on ultrasound from March 2011 to December 2020 in a single medical center. Expectant and interventional management outcomes were compared. Primary outcome was defined as live birth.Forty-one women were diagnosed with heterotopic pregnancy during the study period. Management was expectant in 10 (24.4%) and interventional in 31 (75.6%) of the women. Expectant management was considered when the patient was stable, and the attending physician decided that the 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). The intra-uterine pregnancy continued to develop in 6 (60.0%) and 22 (81.5%) of the women in the expectant and interventional groups, respectively (p = 0.52). All women managed expectantly reached term delivery, as opposed to 17/22 (77.3%) in the intervention management group (p = 0.60). Multivariate analysis found serum β-hCG level as the only independent parameter associated with ongoing pregnancy rate (B = 0.001, p = 0.04).Both expectant and interventional management were found to be acceptable when heterotopic pregnancy was diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.

Recurrence of adnexal torsion (rAT) is reported mainly in small series. Normal and small appearing ovaries are associated with an increased risk for rAT. Nevertheless, updated data of larger cohorts is lacking. We aimed to investigate the predictors for rAT in a cohort of women who had surgical intervention for primary adnexal torsion (pAT).A retrospective case-control study from a single institution between 2011 and 2020. Women with a primary occurrence of surgically proven adnexal torsion were included. We compared those who had experienced rAT to those who had not. Univariate and multivariate analysis were performed to study independent predictors for rAT.Overall, 358 women were included. Of those, 35 (9.8%) had a rAT. Women who experienced rAT were younger (mean age 26 vs. 30 years, p = 0.01). Women experiencing rAT had smaller mean ovarian cyst diameter in the pAT episode (42 vs. 59 mm. p 0.001). Performance of laparoscopic detorsion was only associated with rAT (odds ration [OR] 95% confidence interval [CI] 2.13 [1.02-4.42], p = 0.03), while the performance of additional cystectomy was negatively associated with rAT (OR 95% CI 0.10 [0.01-0.79], p = 0.006). Multivariate analysis demonstrated that age ≤15 and smaller cyst diameter at pAT were independently associated with the risk for rAT (aOR 95% CI 5.0 [1.09-23.2] and 1.47 [1.08-2.0], for every 10 mm decrease in cyst diameter, respectively).Adolescents and pediatric females and women with smaller ovarian cysts at pAT are at higher risk for future recurrence of adnexal torsion.

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

The aim of the study is to learn the obstetrical outcome of women after laparoscopic niche repair.A retrospective cohort study including all women after laparoscopic niche repair done by a single high-skilled surgeon, from July 2014 to March 2019. Data were collected from women's medical records and a telephone interview was performed to assess further symptoms and attempts to conceive, including pregnancy outcomes.During the study period, 48 women underwent laparoscopic niche repair, of them complete follow-up was achieved for 37 (78.7%) women. 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 dehiscence or rupture was reported.Pregnancy following niche repair can be achieved with low pregnancy complication rate and good pregnancy outcomes. Further studies need to be done to strengthen our findings.

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