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Introduction: Millions of women worldwide annually undergo manual vacuum aspiration (MVA) with no pain medication, which is a violation of their basic human dignity. We designed a novel device (Chloe SED®) to administer paracervical block (PCB) during MVA in countries where pain medication is not typically given due to the high cost of the necessary tools. Methods: We conducted a single-blinded, randomized controlled non-inferiority trial including 61 patients at two hospitals in Kisumu, Kenya, to validate Chloe SED® for administration of PCB during MVA. PCB administered with Chloe SED® was compared to PCB administered with a standard spinal needle. Patients requiring MVA were block randomized in blocks of six, each provider completing six PCBs--three with the Chloe SED® and three with the standard spinal needle. The trial was registered with the Kenya Pharmacy and Poisons Board, ECCT/19/03/01 (https://ctr.pharmacyboardkenya.org/applications/index/protocol_no: RUNDVC8xOS8wMy8wMQ__/filter:/investigator:/sites:/pages:5/start_date:/end_ date:/disease_condition:/users:/ercs:/stages). An intention-to-treat analysis was completed. The primary outcome was the non-inferiority of the pain score during uterine evacuation with a non-inferiority margin of 2 points on an 11-point numerical rating scale. Secondary outcomes included the non-inferiority of the pain score at four other time points and patient satisfaction. Results: Chloe SED® showed non-inferiority of the primary outcome with a mean pain score during evacuation of 3.8 [90% confidence interval (CI): 3.1-4.6] compared with the spinal needle at 4.1 (90% CI: 3.5-4.7). Non-inferiority of the pain score was shown at all time points. Most patients expressed a desire for the continued use of the device toadministerPCBforMVA.Noadverse eventswere noted. Conclusion: In summary, the Chloe SED® appears non-inferior to the spinal needle and desirable for the administration of PCB during MVA. [ABSTRACT FROM AUTHOR]

AbstractPurposeMaterials and MethodsResultsConclusionSHORT CONDENSATIONTo evaluate the efficacy and acceptability of virtual reality (VR) as a distraction technique in the management of acute pain and anxiety during outpatient uterine aspiration using a manual vacuum aspirator (MVA).This mixed methods study included a prospective multi-centre randomised controlled trial and structured individual interviews. Of the 72 patients approached, 50 consenting, eligible participants were randomised to VR intervention (immersive video content ‘The Forest of Serenity’) or standard care during MVA for the management of miscarriage or incomplete abortion from July 2021-July 2022 across two university hospitals in London, UK. Expected and actual pain scores, and anxiety before and after the procedure were measured as numeric rating scores (0-10). Structured interviews were undertaken after the procedure in women randomised to VR. Statistical analysis of pain and anxiety scores were by intention-to-treat including all randomised participants, using Stata-12 software. Qualitative analysis was achieved by thematic analysis of transcribed interviews.There was no significant difference in pain or anxiety scores reported by participants randomised to VR compared with standard care. Mean worst pain scores were 5.98 and 6.88 in the standard care and VR groups respectively (p-value 0.13), with corresponding anxiety scores at the end of the procedure 3.94 and 3.3 (p-value 0.57). Qualitative analysis from interviews was highly favourable from women randomised to VR with all participants reporting a positive experience. 90% (18/20) of participants reported that VR reduced their anxiety and 71% (15/21) stated that it helped to reduce or distract from their pain.While virtual reality did not decrease pain or anxiety scores during MVA, it is a feasible and acceptable option that may improve patient experience.Randomisation to VR during MVA did not reduce pain or anxiety scores. However, at structured interview most participants reported that VR reduced their anxiety and reduced or distracted them from their pain. VR is a feasible and acceptable option that may improve patient experience during MVA. [ABSTRACT FROM AUTHOR]

Objective: To identify the risk factors for placenta accreta spectrum (PAS) disorders in women without prior cesarean section (CS). Methods: This retrospective case–control study investigated patients without prior CS who gave birth at Peking University Third Hospital between January 1, 2015 and December 31, 2021. Patients diagnosed with PAS according to the clinical diagnostic criteria of the 2019 International Federation of Gynecology and Obstetrics (FIGO) classification were included as the study group. Patients were matched as the control group according to delivery date and placenta previa, in a 1:2 allocation ratio. Maternal characteristics were compared between the two groups. Results: The study included 348 patients in the study group and 696 in the control group. The multivariate analysis showed that the independent risk factors of PAS consisted of operative hysteroscopy (once: adjusted odds ratio [aOR] 2.38, 95% CI 1.28–4.24, P = 0.006; twice or more: aOR 5.43, 95% CI 1.04–28.32, P = 0.045), uterine curettage (once: aOR 2.54, 95% CI 1.80–3.58, P < 0.001; twice: aOR 3.01, 95% CI 1.81–5.02, P < 0.001; three or more times: aOR 9.18, 95% CI 4.64–18.18, P < 0.001), multifetal pregnancy (aOR 5.64, 95% CI 3.01–10.57, P < 0.001), adenomyosis (aOR 2.77, 95% CI 1.23–6.22, P = 0.014), in vitro fertilization (aOR 1.51, 95% CI 1.04–2.20, P = 0.030) and pre‐eclampsia (aOR 2.72, 95% CI 1.36–5.45, P = 0.005), and the independent protective factor was being multiparous (aOR 0.37, 95% CI 0.25–0.54, P < 0.001). Conclusion: After controlling the effect of placenta previa, we found that patients with PAS without prior CS had unique maternal characteristics. Classification and quantification of the intrauterine surgeries they have undergone is essential for identifying high‐risk patients. Early identification of high‐risk groups by risk factors has the potential to improve the prognosis considerably. Synopsis: Patients with placenta accreta spectrum without prior cesarean section had unique maternal characteristics, and it is essential to classify and quantify the intrauterine surgeries they have previously undergone. [ABSTRACT FROM AUTHOR]

Objective: To investigate the value of ultrasound parameters in assessing the efficacy of transabdominal ultrasound (TAUS)‐guided suction curettage alone for cesarean scar pregnancy (CSP). Methods: Secondary retrospective analysis of a prospective study consisted of 137 women diagnosed with CSP who were performed TAUS‐guided suction curettage alone for the first time at Maternity and Child Health Care of Guangxi Zhuang Autonomous Region in China. Prior to surgery, an ultrasound examination was conducted. Based on the need for secondary intervention, the patients were categorized into failure group and success group, and the predictive factors for failure of TAUS‐guided suction curettage alone were analyzed. Results: Multivariate logistic regression showed that maximum diameter of the gestational sac>29 mm (odds ratio [OR] = 4.043, 95% CI: 1.100–14.862), residual myometrium thickness ≤1.8 mm (OR = 3.719, 95% CI: 1.148–12.048) and chorionic villi thickness at the scar >4.7 mm (OR = 15.327, 95% CI: 4.617–50.881) were independent predictors of failure in TAUS‐guided suction curettage alone for CSP. Furthermore, the logistic regression model that was jointly constructed by these three predictors demonstrated an area under the curve, sensitivity, specificity, and Youden index of 0.913, 0.912, 0.864, and 0.776, respectively. Conclusion: The maximum diameter of the gestational sac, residual myometrium thickness, and chorionic villi thickness at the scar has certain predictive efficacy of TAUS‐guided suction curettage alone for CSP. Nevertheless, it is more valuable to apply the model of this study, composed of the three ultrasound parameters, for this prediction purpose. [ABSTRACT FROM AUTHOR]

Background: Pregnancy-related acute kidney injury (Pr-AKI) is associated with significant maternal and fetal morbidity and mortality, with a three- to four-fold increase in perinatal mortality. Pr-AKI can arise from various obstetric complications, such as hyperemesis gravidarum, septic abortion, hypertensive disorders of pregnancy, pyelonephritis, and antiphospholipid antibody syndrome. Therefore, early diagnosis and appropriate intervention, including the identification of the underlying etiology, are important to effectively manage Pr-AKI. Therefore, we report a case of Pr-AKI after early miscarriage in a patient without hyperemesis gravidarum or septic abortion whose renal function gradually improved postoperatively for miscarriage. Case Presentation: A 34-year-old primigravid woman was referred to us for perinatal management at 6 weeks of gestation. Unfortunately, she was diagnosed with miscarriage 1 week later. The patient had no history of hyperemesis gravidarum or septic abortion; however, she developed oliguria, and her serum creatinine and blood urea nitrogen levels were abnormally increased. Consequently, she underwent a renal biopsy to evaluate renal dysfunction, which indicated tubulointerstitial damage. The patient also underwent manual vacuum aspiration for a miscarriage. Postoperatively, her urine output increased, and her renal function improved. She was determined to have experienced Pr-AKI due to her miscarriage. Conclusion: Our patient had Pr-AKI after a miscarriage in the absence of other causes. This case report highlights the presence of unknown causes of Pr-AKI, warranting further research for the development of preventive interventions. [ABSTRACT FROM AUTHOR]

Background: Intrauterine adhesion (IUA) can arise as a potential complication following uterine surgery, as the surgical procedure may damage the endometrial stratum basalis. The objective of this study was to assess and compare the occurrence of IUA in women who underwent ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum aspiration (EVA) for managing first-trimester miscarriage. Methods: This was a prospective, single-centre, randomised controlled trial conducted at a university-affiliated tertiary hospital. Chinese women aged 18 years and above who had a delayed or incomplete miscarriage of ≤ 12 weeks of gestation were recruited in the Department of Obstetrics and Gynaecology at the Prince of Wales. Recruited participants received either USG-MVA or EVA for the management of their miscarriage and were invited for a hysteroscopic assessment to evaluate the incidence of IUA between 6 and 20 weeks after the surgery. Patients were contacted by phone at 6 months to assess their menstrual and reproductive outcomes. Results: 303 patients underwent USG-MVA or EVA, of whom 152 were randomised to 'USG-MVA' and 151 patients to the 'EVA' group. Out of the USG-MVA group, 126 patients returned and completed the hysteroscopic assessment, while in the EVA group, 125 patients did the same. The incidence of intrauterine adhesion (IUA) was 19.0% (24/126) in the USG-MVA group and 32.0% (40/125) in the EVA group, showing a significant difference (p < 0.02) between the two groups. No significant difference in the menstrual outcomes at 6 months postoperatively between the two groups but more patients had miscarriages in the EVA group with IUA. Conclusions: IUAs are a possible complication of USG-MVA. However, USG-MVA is associated with a lower incidence of IUA postoperatively at 6–20 weeks. USG-MVA is a feasible, effective, and safe alternative surgical treatment with less IUA for the management of first-trimester miscarriage. Trial registration: The study was registered with the Centre for Clinical Research and Biostatics- Clinical Trials Registry (CCRBCTR), which is a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) (Unique Trial Number: ChiCTR1900023198 with the first trial registration date on 16/05/2019) [ABSTRACT FROM AUTHOR]

Background: Cervical ectopic pregnancy (CEP) is a rare diagnosis with few reported cases, making establishment of a standardized treatment challenging. CEPs often require multiple therapeutic modalities and curative surgical management. Case: A patient in her late 40s presented with a persistent CEP after in-vitro fertilization (IVF). Initially, the ectopic pregnancy was treated with ultrasound-guided needle aspiration and multiple doses of methotrexate, but further approaches were necessary to resolve the case. Results: This patient had a CEP with a heartbeat and she had a very high β–human chorionic gonadotropin (β-hCG level). She initially responded appropriately to repeat doses of methotrexate and needle aspiration, but her β-hCG levels eventually plateaued. Eventually, definitive suction curettage, vasopressin injection, and an intracervical Foley balloon tamponade provided a successful resolution. Conclusions: This case highlights further how multimodal treatment methods are valuable for safe resolution of CEPs. The patient at first responded appropriately to multiple doses of methotrexate, which decreased her surgical risks and morbidity significantly. (J GYNECOL SURG 40:44) [ABSTRACT FROM AUTHOR]

Purpose: Ultrasound-guided manual vacuum aspiration (USG-MVA) is a feasible and effective outpatient treatment to treat early pregnancy loss. Methods: This was a prospective observational study at a university-affiliated hospital. All women undergoing either a USG-MVA or electric vacuum aspiration (EVA) were invited to return 3–6 months later for follow-up at which women completed a questionnaire to document their post-evacuation menstrual and reproductive history, and underwent a hysteroscopy if they were not pregnant. The severity of intrauterine adhesion (IUA), if present, was graded (Stage I-III) according to the American fertility society classification. Results: A total of 292 women had a hysteroscopy after their initial surgical evacuation, USG-MVA 169(57.9%) versus EVA 123(42.1%). Women undergoing EVA as opposed to a USG-MVA had a 12.9% higher incidence of IUA (24.1% vs. 37.0%, p = 0.042) equivalent to 1.84 times higher risk (95% CI 1.01–3.34; p = 0.048). Women having EVA continued to show an increased but not statistically significant trend towards an increased risk of IUA after adjusting for the type of miscarriage (aOR = 1.3; 95% CI 0.66–2.50; p = 0.46). Conclusion: There were no significant differences in their reproductive outcomes and fewer women post-USG-MVA complained of hypomenorrhea. IUA may still occur in women undergoing USG-MVA but it is lower than the rate in women undergoing EVA. Clinical trials registry The trial was registered with the Centre for Clinical Research and Biostatistics – Clinical Trials Registry (CCRBCTR), a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) with a Unique Trial Number: CUHK_CCRB00541 on 22 Dec 2016. [ABSTRACT FROM AUTHOR]

BACKGROUND: Unsafe abortion is a neglected women's health issue in India and in many developing nations because maternal mortality and morbidity due to unsafe abortions can easily be prevented when women have access to safe abortion services. We are in a quest of a suitable MTP option for rural India. Electric vacuum aspiration (EVA) succeeded over dilation & curettage as the former is less painful, less time consuming, having lower complication rates and lower maternal mortality. This might serve purpose of remote India to some extent. Material & method: This work was carried out in Post partum centre and Obstetrics & Gynaecology department, hi-tech Medical College and hospital, bhubaneswar during the period July2021-July2023. The cases were pregnant women <12 weeks of gestation attending OBGYN dept of hi-tech medical college and hospital, bhubaneswar for MTP. A total number of 200 patients were studied; out of which 100 patients underwent MVA and the remaining 100 EVA. Result: The mean + SD blood loss is 40 + 10.739 for MVA and 44.88 + 11.296 for EVA. Applying independent sample test, the p value is 0.003. hence MVA is associated with statistically significant less blood loss. In the present study, MVA was effective in 97% and EVA 98% cases, thus the two procedure did not show much difference as far as their effectiveness is concerned. Conclusion: Manual vacuum aspiration is a safe and effective alternative to traditional electric vacuum aspiration. It is also relatively easy to perform and requires simple training for the health care provider. [ABSTRACT FROM AUTHOR]

Background: Management of uterine evacuation is essential for increasing safe abortion care. Monitoring through surveillance systems tracks changes in clinical practice and provides information to improve equity in abortion care quality. Objective: This study aimed to evaluate the frequency of manual vacuum aspiration (MVA) and medical abortion (MA), and identify the factors associated with each uterine evacuation method after surveillance network installation at a Brazilian hospital. Methods: This cross-sectional study included women admitted for abortion or miscarriage to the University of Campinas Women's Hospital, Brazil, between July 2017 and November 2020. The dependent variables were the use of MVA and MA with misoprostol. The independent variables were the patients' clinical and sociodemographic data. The Cochran–Armitage, chi-square, and Mann–Whitney U tests, as well as multiple logistic regression analysis, were used to compare uterine evacuation methods. Results: We enrolled 474 women in the study, 91.35% of whom underwent uterine evacuation via uterine curettage (78.75%), MVA (9.46%), or MA (11.54%). MVA use increased during the study period (Z = 9.85, p < 0.001). Admission in 2020 (odds ratio [OR] 64.22; 95% confidence interval [CI] 3.79–1086.69) and lower gestational age (OR 0.837; 95% CI 0.724–0.967) were independently associated with MVA, whereas the only factor independently associated with MA was a higher education level (OR 2.66; 95% CI 1.30–5.46). Conclusion: MVA use increased following the installation of a surveillance network for good clinical practice. Being part of a network that encourages the use of evidence-based methods provides an opportunity for healthcare facilities to increase access to safe abortions. [ABSTRACT FROM AUTHOR]

Suction curettage is preferred over sharp curettage in obstetric settings. We compare the quality of operative tissue sampling between sharp curettage and suction curettage using electric vacuum aspiration for nonobstetric abnormal uterine bleeding in reproductive-aged women. A retrospective cohort study. Community hospital in Long Island, New York. Women ages 21 to 45 years (n = 257) who underwent operative curettage procedure for nonobstetric abnormal uterine bleeding. Independent ratings of specimens from suction curettage using electric vacuum aspiration and sharp curettage by 2 pathologists blinded to method of tissue collection. The primary outcome was percentage of organized tissue, indicative of a higher-quality pathology specimen. Specimens obtained by electric suction curettage (p <.001) had a significantly higher percentage of organized tissue (M = 66.28, SD = 20.33) than sharp curettage (M = 55.51, SD = 24.17). There were no differences between the curettage groups for operative time, blood loss, intraoperative complications, or pathology diagnosis. Specimens obtained with suction curettage contained more organized tissue with similar pathologist satisfaction and confidence scores than sharp curettage. We suggest clinicians consider electric suction curettage in the diagnostic workup of abnormal uterine bleeding in reproductive-aged women. In addition, patient-centered benefits include no increase in operative time, blood loss, or complication rate compared with sharp curettage. [ABSTRACT FROM AUTHOR]

Gestational trophoblastic disease (GTD) is an abnormal pregnancy caused by the placenta, which can potentially metastasise. Suction evacuation is recommended for diagnosis and treatment, and dilatation and evacuation (D&E) is usually performed under intravenous anaesthesia due to the short operation time and minimal blood loss. We refer to the guidelines produced by the Japan Society of Obstetrics and Gynaecology (JSOG), and acknowledge that practices vary globally. However, to the best of our knowledge, there is no evidence on perioperative management and arrangements in D&E required for managing giant hydatidiform moles, such as preventing massive haemorrhage, respiratory dysfunction with a pathogenesis like ovarian hyperstimulation syndrome (OHSS), or intensive care needs. This case report describes perioperative considerations for managing a giant hydatidiform mole using D&E in a uterus enlarged to the third-trimester pregnancy size. A 28-year-old multiparous woman was clinically diagnosed with a hydatidiform mole after a spontaneous miscarriage due to abnormal genital bleeding, systemic oedema, and abdominal distention. Ultrasound and computed tomography showed a ballooning uterus with a third-trimester pregnancy size, a robust intrauterine mass, and ascites. Serum hCG levels were extremely high (>3,000,000 mIU/mL), confirming the clinical diagnosis of a hydatidiform mole. Emergency D&E was safely performed under multidisciplinary perioperative management, with careful preparation and support. This is a rare experience-based case report and valuable documentation detailing multidisciplinary perioperative management under general anaesthesia. To the best of our knowledge, this is the first report describing the considerations, details, and innovations required in the perioperative management of giant hydatidiform moles using D&E.

Objective: To determine how many times Ipas manual vacuum aspiration (MVA) instruments are reused, for what reasons, when the instruments are replaced and/or discarded, and what the barriers are to replacing them. Methods: We conducted a mixed‐methods cross‐sectional study of health care providers who provide MVA services and key stakeholders in the supply chain to understand reuse and replacement of Ipas MVA aspirators and cannulae. Qualitative interviews focused on procurement and replacement of Ipas MVA instruments. Results: The authors interviewed 352 health care providers from nine countries from 2019 to 2021. Providers reported reusing MVA instruments an average of 34.4 times (standard deviation, 45). The reuse averages ranged from one time (Democratic Republic of the Congo) to 500 times (India), with figures varying between providers within the same country. Instrument malfunctioning rather than a specific number of uses drove reuse and subsequent replacement. The decision to replace was most commonly made by the provider during use. Half of the providers said that they knew of no issues with the supply chain, and 85% said they were always able to replace Ipas MVA instruments when needed. Conclusion: Tracking reuse of MVA instruments was uncommon at participating providers' health facilities. Providers' estimates revealed great variability in reuse frequency and tracking procedures. Synopsis: Tracking reuse of manual vacuum aspiration instruments was uncommon at participating providers' health facilities. Providers' estimates revealed great variability in reuse frequency and tracking procedures. [ABSTRACT FROM AUTHOR]

Background: Nontyphoidal Salmonella serovars predominantly cause gastrointestinal infections. However, other clinical presentations, including urogenital infections, have been reported, although they are rather rare. Case presentation: This case is about a 33-year-old woman diagnosed with Salmonella enterica serovar Hvittingfoss (S. Hvittingfoss) bacteremia and endometritis six days post uterine aspiration in the context of a missed abortion. She had traveled to Indonesia two weeks prior to the positive blood and cervical culture. She never developed gastrointestinal symptoms but was found to carry S. Hvittingfoss in her stool sample. The patient was successfully treated with a seven-day course of iv ciprofloxacin. Conclusions: S. Hvittingfoss is a rare serovar that has caused a few outbreaks of foodborne infections in Asia, the United States, and Australia. To the best of our knowledge, this is the first reported case of Salmonella urogenital infection caused by this serovar. Salmonella as a cause of urogenital infections is rare but not uncommon. Therefore, it should be considered in identifying members of the Enterobacterales among urogenital flora in cases of severe urogenital infections, especially when other cultures remain negative. [ABSTRACT FROM AUTHOR]

Background: The goal of the current study was to evaluate the effectiveness, safety, acceptability, and degree of satisfaction of medical method vs manual vacuum aspiration (MVA) in first-trimester pregnancies with clinically confirmed missed miscarriages. Methods: From January 2021 to December 2022, a comparative interventional study on 100 clinically diagnosed first trimester missed miscarriages of gestational ages less than 12 weeks pog was undertaken at the Department of Obstetrics & Gynecology, Guntur Medical College, Guntur. Group A consisted of 50 patients who chose the medical procedure, and group B consisted of 50 patients who chose manual vacuum aspiration. Results: The mean age of the patients in MVA group was 23.6 and in the medical management group was 24.6. The mean gestational age was 67.5 days for the MVA group and 70.1 days for the MM group. The median value differences of Gravida, Para, Live and abortions between both the groups is not significant. The difference in pallor before intervention in both the groups is not significant at p>0.05. The difference in blood loss between both the groups is significant at p value <0.05. There is a significant amount of blood loss in medical management group compared to MVA group. The difference in both the groups for efficacy in terms of retained products of contraception during TVS/TAS scan is significant at p <0.05. MVA is better than medical management in terms of efficacy in managing missed abortions. The difference between the duration of hospital stay between both the groups is significant at p-value <0.05. The duration of hospital stay with MVA is shorter than with medical methods. The difference in pain by VAS is statistically significant between both the groups at p<0.0001. Pain according to Visual Analogue Score is more in medical management compared to MVA group. Patient satisfaction is more in MVA group compared to medical management group. Conclusions: Comparing the medical approach to MVA method, there is more bleeding per vaginum; this implies safety. Less patients left AMA/absconded, which led to a high satisfaction percentage in the MVA group. Because there were more cases of complete evacuation in the MVA group, the MVA mode of abortion in the current study was more effective. Due to shorter hospital stay, the MVA group had a higher patient acceptability rate than the medical group. The MVA is thereby demonstrated to be a more effective, safe, acceptable, and satisfying method than medical management. [ABSTRACT FROM AUTHOR]

Introduction: Manual vacuum aspiration (MVA) is a safe and effective alternative option for the management of first‐trimester miscarriage, termination of pregnancy, or retained pregnancy tissue. Ireland's first MVA clinic was set up in the Rotunda Hospital in April 2020. Objective: To identify the number of women who have undergone MVA since establishing our service, to assess the efficacy and safety of MVA in that service, and to develop local Irish studies that further support the safety of MVA, adding to the international body of evidence. Methods: With the approval and assistance of the Clinical Audit Committee, we obtained a log of all patients who underwent MVA in the first 18 months of the service. We performed a retrospective electronic chart review using Maternal and Newborn Clinical Management System. We collected the data and preformed a descriptive analysis. Results: In total, 86 women underwent MVA, 85 (98.8%) of which were successfully completed. There were no immediate procedural complications, inter‐hospital transfers, or emergency electric vacuum aspiration (EVA) required. We obtained an incomplete evacuation rate of 4.7% (n = 4). Conclusion: We have demonstrated that the MVA service in the Rotunda Hospital is a safe, effective management option with advantages for both the patient and the healthcare system. We recommend consideration for provision of funding and resources to enable expansion of this service nationally in order to give women greater autonomy of choice in the management of early pregnancy complications and termination of pregnancy. Synopsis: The results of this retrospective audit of a new MVA service in Ireland demonstrate that MVA is a safe and effective option for the management of miscarriage and pregnancy termination. [ABSTRACT FROM AUTHOR]

Introduction: In the first trimester, almost one in five identified pregnancies end in spontaneous miscarriage, and another 22% result in induced abortion. After a spontaneous and/or induced abortion, there may be retained products of conception (POC). Because of its relatively poor efficacy and the unpredictability of the time interval until spontaneous evacuation, expectant treatment is not often chosen by healthcare professionals. In view of these facts, the current study's objective was to weigh the effectiveness of MVA and oral misoprostol 600 mg in managing incomplete abortion. Materials and Procedures: The investigation was conducted at the tertiary care center in India. The survey was conducted for one year. Subjects were selected from those attending the department for either spontaneous or induced abortions. A total of 230 women were randomly assigned to receive the interventions of a single dose of oral misoprostol 600 mcg or MVA. They were equally distributed to two groups and observed for the various parameters of success, signs and symptoms, satisfaction, and complications. The obtained values were compared statistically for the significance at <0.05 of P values. Results: Of the 200 subjects (30 lost to follow-up), there was no significant variance in the demographics, clinical outcomes, and complications between the groups. However, the pain, fever, shivering, and satisfaction parameters were statistically variant between the groups. Fever, shivering, and pain were lower for the MISO subjects while satisfaction was reported higher from subjects in MISO group. Conclusion: MISO and MVA are acceptable, safe, and efficient therapies for first-trimester un-complicated incomplete abortion. Nonetheless, misoprostol appears to be a marginally superior option to MVA in terms of accessibility, low therapy costs, reduced pain, and reduced demand for specialized personnel or equipment. [ABSTRACT FROM AUTHOR]

Background and objectives: In Kenya, where abortion is legally restricted, most abortions are induced using unsafe procedures, and lead to complications treated in public health facilities. The introduction of Manual Vacuum Aspiration (MVA) to treat incomplete abortion has improved the management of abortion complications. However, this technology comes with pain whose management has been a challenge. This paper explores the lived experiences of pain (management) during MVA to document the contributing factors. Methods: We used an ethnographic approach to explore girls and healthcare providers' experiences in offering and accessing post-abortion care in Kilifi County, Kenya. The data collection approach included participant observation and informal conversations in public health facilities and neighboring communities, as well as in-depth interviews with 21 girls and young women treated for abortion complication and 12 healthcare providers. Results: Our findings show that almost all patients described the MVA as the most painful procedure they have ever experienced. The unbearable pain was explained by various factors, including the lack of preparedness of health facilities to offer PAC services (i.e. lack of pain medicine, lack of training, inadequate knowledge and grasp of pain medication guidelines, and malfunctioning MVA kits). Moreover, the attitudes of healthcare providers and facilities management toward the MVA device limited the supply and replacement of MVA kits. Moreover, the scarcity of pain medicines also gave some providers the opportunity to abuse patients guided by their values, whereby they would deny patients pain medication as a form of "punishment" if they were suspected of inducing their abortion, especially adolescent girls. Conclusion: The study findings suggest the need for clearer guidelines on pain medication, value clarification and attitude transformation training for providers, systematizing the use of medical uterine evacuation using medical abortion drug and strengthening the supply chain of pain medication and MVA kits to reduce the pain and improve the quality of post-abortion care. [ABSTRACT FROM AUTHOR]

STUDY QUESTION Can multiple-site low-pass genome sequencing (GS) of products of conception (POCs) improve the detection of genetic abnormalities, especially heterogeneously distributed mosaicism and homogeneously distributed mosaicism in first-trimester miscarriage? SUMMARY ANSWER Multiple-site sampling combined with low-pass GS significantly increased genetic diagnostic yield (77.0%, 127/165) of first-trimester miscarriages, with mosaicisms accounting for 17.0% (28/165), especially heterogeneously distributed mosaicisms (75%, 21/28) that are currently underappreciated. WHAT IS KNOWN ALREADY Aneuploidies are well known to cause first-trimester miscarriage, which are detectable by conventional karyotyping and next-generation sequencing (NGS) on a single-site sampling basis. However, there are limited studies demonstrating the implications of mosaic genetic abnormalities in first-trimester miscarriages, especially when genetic heterogeneity is present in POCs. STUDY DESIGN, SIZE, DURATION This is a cross-sectional cohort study carried out at a university-affiliated public hospital. One hundred seventy-four patients diagnosed with first-trimester miscarriage from December 2018 to November 2021 were offered ultrasound-guided manual vacuum aspiration (USG-MVA) treatment. Products of conception were subjected to multiple-site low-pass GS for the detection of chromosomal imbalances. PARTICIPANTS/MATERIALS, SETTING, METHODS For each POC, multiple sites of villi (three sites on average) were biopsied for low-pass GS. Samples with maternal cell contamination (MCC) and polyploidy were excluded based on the quantitative fluorescence polymerase chain reaction (QF-PCR) results. The spectrum of chromosomal abnormalities, including mosaicism (heterogeneously distributed and homogeneously distributed) and constitutional abnormalities was investigated. Chromosomal microarray analysis and additional DNA fingerprinting were used for validation and MCC exclusion. A cross-platform comparison between conventional karyotyping and our multiple-site approach was also performed. MAIN RESULTS AND THE ROLE OF CHANCE One hundred sixty-five POCs (corresponding to 490 DNA samples) were subjected to low-pass GS. Genetic abnormalities were detected in 77.0% (127/165) of POCs by our novel approach. Specifically, 17.0% (28/165) of cases had either heterogeneously distributed mosaicism (12.7%, 21/165) or homogeneously distributed mosaicism (6.1%, 10/165) (three cases had both types of mosaicism). The remaining 60.0% (99/165) of cases had constitutional abnormalities. In addition, in the 71 cases with karyotyping performed in parallel, 26.8% (19/71) of the results could be revised by our approach. LIMITATIONS, REASONS FOR CAUTION Lack of a normal gestational week-matched cohort might hinder the establishment of a causative link between mosaicisms and first-trimester miscarriage. WIDER IMPLICATIONS OF THE FINDINGS Low-pass GS with multiple-site sampling increased the detection of chromosomal mosaicisms in first-trimester miscarriage POCs. This innovative multiple-site low-pass GS approach enabled the novel discovery of heterogeneously distributed mosaicism, which was prevalent in first-trimester miscarriage POCs and frequently observed in preimplantation embryos, but is currently unappreciated by conventional single-site cytogenetic investigations. STUDY FUNDING/COMPETING INTEREST(S) This work was supported partly by Research Grant Council Collaborative Research Fund (C4062-21GF to K.W.C), Science and Technology Projects in Guangzhou (202102010005 to K.W.C), Guangdong-Hong Kong Technology Cooperation Funding Scheme (TCFS), Innovation and Technology Fund (GHP/117/19GD to K.W.C), HKOG Direct Grant (2019.050 to J.P.W.C), and Hong Kong Health and Medical Research Fund (05160406 to J.P.W.C). The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER N/A. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate abortion completion after self-managed medication abortion in pregnancies at or beyond 9 weeks of gestation. METHODS: We conducted a prospective observational cohort study in which we recruited callers to three abortion-accompaniment groups in Argentina, Nigeria, and Southeast Asia who were initiating a self-managed medication abortion. Participants completed a baseline survey over the phone before taking pills and then two follow-up phone surveys 1 and 3 weeks after taking pills. The primary outcome was abortion completion; secondary outcomes included physical experiences and health care seeking and treatment. RESULTS: Between 2019 and 2020, we enrolled 1,352 participants, 19.5% (264/1,352) of whom self-managed a medication abortion at 9 or more weeks of gestation: 75.0% (198/264) at 9–11 weeks, 19.3% (51/264) at 12–14 weeks, and 5.7% (15/264) at 15–22 weeks. Participants were aged 26 years on average (SD 5.6 years); 56.4% (149/264) used the combined regimen (mifepristone+misoprostol), and 43.6% (115/264) used misoprostol only. At the last follow-up, 89.4% (236/264) had a complete abortion without procedural intervention, 5.3% (14/264) had a complete abortion with manual vacuum aspiration or dilation and curettage procedure, 4.9% (13/264) had an incomplete abortion, and 0.4% (1/264) participants did not report an abortion outcome. Some participants (23.5%, 62/264) sought health care during or after the self-managed medication abortion, most commonly to confirm completion (15.9%, 42/264); 9.1% (24/264) needed further medical intervention (procedural evacuation, antibiotics, additional misoprostol, intravenous fluids, blood transfusion, or overnight stay in the facility). Those who were 12 or more weeks pregnant were more likely to seek care at a clinic or hospital than those who were 9–11 weeks pregnant (adjusted relative risk 1.62, 95% CI 1.3–2.1). CONCLUSION: People who self-managed an abortion with medication between 9 and 16 weeks of gestation had high levels of abortion completion and accessed health care to confirm completion or to treat potential complications. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of manual vacuum aspiration and conventional evacuation & curettage (ENC) for first-trimester miscarriage management. Materials and Methods: This quasi-experimental study was carried out at the Department of Gynecology and Obstetrics, Khyber Teaching Hospital, Peshawar, Pakistan from October 2022 to March 2023 including 150 patients with first trimester miscarriage dividing them into two groups (MVA and ENC) having equal number of patients. Efficacy in both groups was compared. Results: The mean age in the MVA group (group A) was 27.81±6.31years while in the ENC group (group B) it was 26.50±6.27 years. The mean gestational age in group A was 5.82±2.82 weeks while in group B it was 5.95±2.9 weeks. MVA was effective in 88% of participants while ENC was effective in 93.33% of participants (p-value, 261), which is not statistically significant. Conclusion: Surgical uterine evacuation utilizing MVA under local anesthetic is safe and successful, and it should be considered to minimize a lengthy hospital stay. MVA can be a viable alternative to surgical curettage like ENC. It is safe, cost-effective, and simple to conduct, eliminating general anesthetic, the requirement for theatre access, and an unnecessary hospital stay. [ABSTRACT FROM AUTHOR]

The article focuses on comparing operative hysteroscopy and vacuum aspiration for the management of incomplete spontaneous abortion in women. It mentions the study found no difference in pregnancy rates within two years between the two techniques and concluded that operative hysteroscopy did not provide any advantages over vacuum aspiration.

Introduction: Both, surgical and medicinal techniques can be used vaginally to treat incomplete abortions. Although, Manual Vacuum Aspiration (MVA) is a safe and efficient surgical treatment for the management of incomplete abortion, it is not frequently offered and is not very cost effective in rural areas, especially in low resource settings. Misoprostol is an alternative to MVA for the treatment of incomplete abortion. Aim: To assess the effectiveness and acceptability of using vaginal misoprostol for the management of first trimester spontaneous incomplete abortion as an alternative to MVA. Materials and Methods: A randomised clinical trial was conducted between February 2020 to July 2021 in the Department of Obstetrics and Gynaecology, at RG Kar Medical College and Hospital, Kolkata, West Bengal, India. A total of 144 participants were randomised into two groups with 72 women in each group, to treatment with either MVA or 400 mcg vaginal at 3 hour intervals. The main outcome measures assessed at 24 hour follow-up were complete uterine evacuation confirmed by transvaginal sonography, and client acceptability and satisfaction were assessed from entry in data form by participants. Chi-square (χ²) tests were used for categorical data, and the Student's paired t-test was used for continuous data. Statistical significance in all calculations was defined as p<0.05 and the study would follow the Intention To Treat (ITT) analysis while computing the results. Results: The mean ages were 27.44 years (6.8) and 28.47 years (6.6) for the misoprostol and MVA groups respectively. For the gestational age, the mean gestational ages were 8.88 (2.01) and 8.90 (2.17) weeks for the misoprostol and MVA groups, respectively. A higher failure rate in terms of incomplete abortion was encountered in the misoprostol arm compared to the MVA arm. Although this difference in complete uterine evacuation rate did not reach statistical significance (RR=4, 95% Confidence Interval (CI) 0.879-18.192, p=0.0728). Pyrexia appeared to be a significant complication in the misoprostol group compared to MVA group (p=0.038). There was no significant difference in satisfaction in both groups (p=0.659) and no significant difference in acceptability. Conclusion: As an alternative to surgical intervention, three 400 mcg misoprostol pills could be administered vaginally over the course of three hours to treat spontaneous first trimester uncomplicated incomplete abortion. [ABSTRACT FROM AUTHOR]

ObjectiveTo estimate the efficacy and safety of mifepristone antagonization with high-dose oral progesterone.MethodsWe planned to enroll 40 patients in a double-blind, placebo-controlled, randomized trial. We enrolled patients at 44-63 days of gestation with ultrasound-confirmed gestational cardiac activity who were planning surgical abortion. Participants ingested mifepristone 200 mg and initiated oral progesterone 400 mg or placebo 24 hours later twice daily for 3 days, then once daily until their planned surgical abortion 14-16 days after enrollment. Follow-up visits were scheduled 3±1, 7±1, and 15±1 days after mifepristone intake with ultrasonography and blood testing for human chorionic gonadotropin and progesterone. Participants exited from the study when they had their surgical abortion or earlier for gestational cardiac activity absence, gestational sac expulsion, or medically indicated suction aspiration. We assessed the primary outcome of continued gestational cardiac activity at approximately 2 weeks (15±1 day), side effects after drug ingestion, and safety outcomes including hemorrhage and emergent treatment.ResultsWe enrolled participants from February to July 2019 and stopped enrollment after 12 patients for safety concerns. Mean gestational age was 52.5 days. Two (one per group) voluntarily discontinued 3 days after mifepristone ingestion for subjective symptoms (nausea and vomiting, bleeding). Among the remaining 10 patients (five per group), gestational cardiac activity continued for 2 weeks in four in the progesterone group and two in the placebo group. One patient in the placebo group had no gestational cardiac activity 3 days after mifepristone use. Severe hemorrhage requiring ambulance transport to hospital occurred in three patients; one received progesterone (complete expulsion, no aspiration) and two received placebo (aspiration for both, one required transfusion). We halted enrollment after the third hemorrhage. No other significant side effects were reported.ConclusionWe could not estimate the efficacy of progesterone for mifepristone antagonization due to safety concerns when mifepristone is administered without subsequent prostaglandin analogue treatment. Patients in early pregnancy who use only mifepristone may be at high risk of significant hemorrhage.Clinical trial registrationClinicalTrials.gov, NCT03774745.

Objective: To explore the feasibility of sampling Chinese patients by suction curettage for cytological and histological screening of endometrial cancer related to Lynch syndrome. Methods: This retrospective study enrolled patients who underwent endometrial biopsy at our hospital between May 2018 and January 2019. Endometrial sampling (cytological and micro-histological specimens) was conducted by suction curettage. The gold standard for diagnosis was traditional sharp dilation and curettage (D&C). The sensitivity, specificity, and diagnostic accuracy of cytology, micro-histology, and the combination of cytology and micro-histology were calculated. Additionally, receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic efficiency of three screening methods. Mismatch repair proteins were further detected using immunohistochemistry (IHC) in endometrial cancer. Results: This retrospective finally enrolled 100 patients, which satisfactory samples were obtained from 96 patients for liquid-based cytology and 93 patients for microtissue histology. The concordance rates with D&C, sensitivity, and specificity were 94.8%, 76.9%, and 97.5% for liquid-based cytology, 96.8%, 84.6%, and 98.8% for microtissue histology, and 99.0%, 92.3%, and 100.0% for liquid-based cytology and microtissue histology combined, respectively. The AUC of ROC curves in liquid-based cytology, microtissue histology, and the combined methods for diagnostic ability were 0.873, 0.917, and 0.962, respectively. Absence rates of MLHl, MSH2, MSH6, and PMS2 proteins were 15.3% (2/13), 0% (0/13), 7.7% (1/13), and 15.3% (2/13) in the 13 endometrial cancer samples. Conclusion: Liquid-based cytology and microtissue histology samples from suction curettage combined IHC are useful for endometrial cancer screening. [ABSTRACT FROM AUTHOR]

Mifepristone–misoprostol and office uterine aspiration used for abortion care are also evidence-based, cost-effective strategies for early pregnancy loss management. We aimed to compare the provision of mifepristone-misoprostol and office uterine aspiration for early pregnancy loss between states with restrictive and supportive abortion policies. We conducted a cross-sectional, internet-based survey regarding early pregnancy loss management among obstetrician–gynecologists (OBGYNs) at academic medical centers. We assessed management offered along with facilitators and barriers to implementation of mifepristone–misoprostol and office uterine aspiration. We used χ2 and multivariable logistic regression to compare practice patterns. We analyzed responses from 350 physicians, 56% from states with restrictive abortion policies. OBGYNs in states with restrictive abortion policies were less likely than those in states with supportive abortion policies to offer both mifepristone–misoprostol and office uterine aspiration (33.2% vs. 51.3%; p =.001), to report having received induced abortion training (67.3% vs. 89.6%; p <.001), and to report perceived institutional support for abortion care (49.0% vs. 85.0%; p <.001). After adjusting for confounders, restrictive state policy was no longer associated with providing both mifepristone-misoprostol and office uterine aspiration for early pregnancy loss (adjusted odds ratio, 1.19; 95% confidence interval [CI], 0.58–2.45). However both prior induced abortion training and institutional support for abortion care remained significantly associated (adjusted odds ratio, 2.06; 95% CI, 1.07–3.97 and adjusted odds ratio, 3.91; 95% CI, 2.08–7.38, respectively). OBGYNs practicing in states with restrictive abortion policies are less likely than those in states with supportive abortion policies to have received abortion training or perceive institutional support for abortion care, and they are less likely to offer mifepristone–misoprostol and office uterine aspiration for early pregnancy loss. [ABSTRACT FROM AUTHOR]

Low but rising serum human chorionic gonadotropin (hCG) levels occur infrequently after an induced abortion. Because this scenario rarely occurs after suction aspiration, clinicians may have higher suspicion for an uncommon diagnosis. The differential diagnosis includes both common and uncommon diagnoses, such as incomplete abortion, heterotopic or ectopic pregnancy, a new intrauterine pregnancy and gestational trophoblastic neoplasia. The etiology of this presentation may be unclear, especially in the absence of abnormal bleeding or pain which would suggest incomplete abortion, or when significant time has passed since the procedure. We describe two cases of an uncommon presentation of retained products of conception after aspiration abortion in which hCG levels were low but rising.

Background: Gestational trophoblastic neoplasia (GTN) is a group of tumors highly responsive to chemotherapy. It has been suggested that cancer therapies have detrimental effects on female fertility. Anti-Müllerian hormone (AMH) is considered fertility potential and ovarian reserves in women. The aim of this study was to compare serum AMH levels between the patients with GTN treated with chemotherapy and the patients with hydatidiform mole who underwent suction curettage without receiving any chemotherapy. Methods: In 35 patients with GTN, serum AMH levels were measured before suction curettage and after the administration of chemotherapy and compared with serum AMH levels measured in 35 patients with hydatidiform mole, who did not receive any chemotherapy as a control. In controls, serum levels of AMH were measured before suction curettage and at the time when beta human chorionic gonadotrophin (ß-hCG) levels approached zero concentration. Results: The mean serum AMH levels in the GTN group were significantly lower than those measured in the control group after chemotherapy. In addition, serum AMH levels measured after intervention in each group significantly decreased compared to the basal levels (p=0.034). Serum AMH levels showed significant differences between the patients who received chemotherapy regimens with methotrexate (MTX) alone, actinomycin-D (Act-D) alone, or the combination of MTX and Act-D (p=0.001). Conclusion: Our study showed that fertility preservation is of great importance in patients with GTN treated with chemotherapy. Furthermore, both MTX and Act-D could have potential adverse effects on ovarian reserve. [ABSTRACT FROM AUTHOR]

Background: In Malawi, abortion is only legal to save a pregnant woman's life. Treatment for complications after unsafe abortions has a massive impact on the already impoverished health care system. Even though manual vacuum aspiration (MVA) and misoprostol are the recommended treatment options for incomplete abortion in the first trimester, surgical management using sharp curettage is still one of the primary treatment methods in Malawi. Misoprostol and MVA are safer and cheaper, whilst sharp curettage has more risk of complications such as perforation and bleeding and requires general anesthesia and a clinician. Currently, efforts are being made to increase the use of misoprostol in the treatment of incomplete abortions in Malawi. To achieve successful implementation of misoprostol, health care providers' perceptions on this matter are crucial.Methods: A qualitative approach was used to explore health care providers' perceptions of misoprostol for the treatment of incomplete abortion using semi-structured in-depth interviews. Ten health care providers were interviewed at one urban public hospital. Each interview lasted 45 min on average. Health care providers of different cadres were interviewed in March and April 2021, nine months after taking part in a training intervention on the use of misoprostol. Interviews were recorded, transcribed verbatim and analyzed using 'Systematic Text Condensation'.Results: The health care providers reported many advantages with the increased use of misoprostol, such as reduced workload, less hospitalization, fewer infections, and task-shifting. Availability of the drug and benefits for the patients were also highlighted as important. However, some challenges were revealed, such as deciding who was eligible for the drug and treatment failure. For these reasons, some health care providers still choose surgical treatment as their primary method.Conclusion: Findings in this study support the recommendation of increased use of misoprostol as a treatment for incomplete abortion in Malawi, as the health care providers interviewed see many advantages with the drug. To scale up its use, proper training and supervision are essential. A sustainable and predictable supply is needed to change clinical practice. Unsafe abortion is a major contributor to maternal mortality worldwide. Unsafe abortion is the termination of an unintended pregnancy by a person without the required skills or equipment, which might lead to serious complications. In Malawi, post-abortion complications are common, and the maternal mortality ratio is among the highest in the world. Retained products of conception, referred to as an incomplete abortion, are common after spontaneous miscarriages and unsafe induced abortions. There are several ways to treat incomplete abortion, and the drug misoprostol has been successful in the treatment of incomplete abortion in other low-income countries. This study explored perceptions among health care providers using misoprostol to treat incomplete abortions and whether the drug can be fully embraced by Malawian health care professionals. Health personnel at a Malawian hospital were interviewed individually regarding the use of the drug for treating incomplete abortions. This study revealed that health care providers interviewed are satisfied with the increased use of misoprostol. They highlighted several benefits, such as reduced workload and that it enabled task-shifting so that various hospital cadres could now treat patients with incomplete abortions. The health care workers also observed benefits for women treated with the drug compared to other treatments. The challenges mentioned were finding out who was eligible for the drug and drug failure. This study supports scaling up the use of misoprostol in the treatment of incomplete abortions in Malawi; the Ministry of Health and policymakers should support future interventions to increase its use. [ABSTRACT FROM AUTHOR]

This article discusses a pilot study that aimed to evaluate the use of virtual reality (VR) as a distraction technique during manual vacuum aspiration (MVA) treatment of miscarriage. The study found that most women who used VR reported a reduction in procedural anxiety and pain, as well as an improved overall experience. However, there was no significant difference in pain or anxiety scores between the VR group and the group without VR during or after the procedure. Overall, the study suggests that VR can be a useful tool in improving patient experience during MVA, but further research is needed to eliminate potential biases. [Extracted from the article]

Aim: Endometrial biopsy is generally performed with a metal uterine curette sonde; however, recently, many types of vacuum aspirators are available, including the manual vacuum aspiration (MVA) system. We used the women's MVA system for endometrial sampling and evaluated its effectiveness in determining the presence of endometrial malignancy. Methods: Forty‐seven samples were examined using the following procedures after measuring endometrial thickness by transvaginal ultrasonography: fractional curettage biopsy (Bx; 20 samples), total curettage under general anesthesia (T/C; 13 samples), and MVA (14 samples). The quality of the endometrial samples was classified into four types: 1–4, where 1 denoted poor and 4, good quality. Results: The mean score of the MVA group was significantly higher than that of the partial curettage biopsy group (p = 0.0065). No differences were observed between the MVA and total curettage groups (p = 1.00). When patients were divided into two groups according to endometrial thickness (<10 mm or ≥10 mm) and analyzed, both the MVA and T/C groups did not show a significant difference in their scores compared to the Bx group when the endometrial thickness was <10 mm. However, when the endometrial thickness was ≥10 mm, the MVA and T/C groups had significantly better scores than the Bx group (p = 0.0225 and p = 0.0244, respectively). Vagal reflex, as an adverse event, was observed only in two patients in the Bx group (2/20, 10%). Conclusion: Considering its quality and safety, Karman‐type MVA for endometrial sampling could be an alternative to fractional curettage using a metallic uterine curette sonde. [ABSTRACT FROM AUTHOR]

Background: Oxytocin is commonly used to reduce blood loss during suction curettage for missed abortion. However, the potential of oxytocin to mitigate blood loss in early pregnancy remains controversial. Based on the hypothesis that the "timing" of oxytocin administration may be a critical factor, we investigated whether the timing of intravenous (IV) administration is associated with reduced perioperative blood loss during first-trimester suction curettage for missed abortion. Methods: The medical charts of 146 patients with ultrasound-confirmed first-trimester missed abortion who underwent suction curettage with IV oxytocin administration were retrospectively reviewed. Results: Among the patients, 67 received 10 IU of IV oxytocin before suction curettage (early-oxytocin administration group), while 79 patients received 10 IU of IV oxytocin after suction curettage (late-oxytocin administration group). The demographic features between the two groups did not significantly differ. However, there was a lower proportion of nulliparous patients in the early-oxytocin administration group than in the late-oxytocin administration group (38.8% vs 60.8%, p = 0.006). The perioperative blood loss amount was significantly lower in the early-oxytocin administration group than in the late-oxytocin administration group (60 [range: 50-100] vs 100 [range: 30-250] mL, p = 0.001). Moreover, the multivariate logistic regression analysis showed that the early-oxytocin administration group had a lower risk for a perioperative blood loss amount of >100 mL than the late-oxytocin administration group (0.23 [range: 0.10-0.55], p = 0.001); a gestational age of 9-12 weeks (p = 0.009) was found to be associated with an increased risk for a perioperative blood loss amount of ≥100 mL. Conclusion: Compared with late-oxytocin administration, early-oxytocin administration could reduce perioperative blood loss during first-trimester suction curettage for missed abortion. However, the results require further investigation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether administration of intranasal fentanyl reduces reported pain during first-trimester uterine aspiration.Study Design: We conducted a multicenter, randomized, double-blind, placebo-controlled trial of patients with pregnancies less than or equal to 14 weeks gestation seeking uterine aspiration for induced abortion, early pregnancy loss, or failed medication abortion. We randomized participants 1:1 to either intranasal fentanyl 100 mcg or intranasal placebo. All participants received ibuprofen and a standardized paracervical block. The primary outcome was pain indicated at the time of uterine aspiration on a 100 mm visual analog scale (VAS). We designed the study to detect a 15 mm difference in mean pain scores, which required 53 people in each arm for a total of 106 participants. Secondary outcomes included postprocedure pain and patient satisfaction with pain control.Results: From March 2017 through June 2018, we screened 355 people for eligibility and enrolled 107 participants. Those who received intranasal fentanyl reported similar uterine aspiration pain to participants who received placebo (58.4 ± 28.0 fentanyl vs 58.6 ± 24.5 placebo, p = 0.97). Participants who received intranasal fentanyl also reported similar postprocedure pain scores compared to participants who received placebo (19.1 ± 19.4 fentanyl vs 17.2 ± 19 placebo, p = 0.63), and were equally satisfied with procedure pain control (66.8 ± 31.2 fentanyl vs 63.3 ± 29.2 placebo, p = 0.57).Conclusion: Intranasal fentanyl did not decrease reported pain with first-trimester uterine aspiration, nor did it decrease postprocedure pain compared to placebo. As an adjunct to ibuprofen and paracervical block, intranasal fentanyl did not improve patient satisfaction with pain control.Implications: Intranasal fentanyl does not reduce reported pain with first-trimester uterine aspiration, however abortion-seeking patients are amenable to receiving intranasal medications for pain management. [ABSTRACT FROM AUTHOR]

Objective: To measure the difference in procedure time between manual vacuum aspiration (MVA) and electric vacuum aspiration (EVA) during abortion procedures between 10 0/7 and 13 6/7 weeks gestation.Study Design: We conducted a 1:1 randomized trial of individuals undergoing an abortion procedure between 10 0/7 and 13 6/7 weeks to MVA or EVA. Procedure time was the primary outcome. We performed an intention-to-treat analysis. A total of 132 patients (66 per arm) were needed to identify a 2-minute difference in time with 90% power and an alpha of 0.05. Given the non-parametric distribution of procedure times, we used Mann-Whitney U test to assess for differences in median procedure times.Results: We randomized 146 participants; 74 to MVA and 72 to EVA. Median procedure times were similar between the 2 groups; EVA 2.4 minutes (range 0.9-6.9 min) and MVA 2.6 minutes (range 1.1-9.0 min, p = 0.12). When stratified by gestational age, EVA between 12 0/7 and 13 6/7 weeks had a shorter median procedure time compared to MVA (2.5 min, range 1.4-6.9 min vs. 3.5 min range 1.7-9.0), respectively (p = 0.005). One conversion occurred from MVA to EVA at 13 weeks.Conclusion: We found no difference in procedure time between MVA and EVA between 10 0/7 and 13 6/7 weeks gestation. MVA does take 1 minute longer than EVA when performed between 12 0/7-13 6/7 weeks; however, this difference is not likely be clinically significant.Implications: Procedure times are similar for manual and electric vacuum aspiration for uterine evacuation between 10 and 14 weeks and the rate of conversion is low. [ABSTRACT FROM AUTHOR]

Background: Cesarean scar pregnancy (CSP), a rare iatrogenic form of ectopic pregnancy (EP), cause of severe maternal morbidity. Each subtype of CSP needs different treatment and there is no consensus about this topic. Despite improvements, the lack of universally accepted therapeutic management and discordance present in literature indicates that treatment has been mainly based on experiences reported., Methods: A case series of our double combined approach with methotrexate (MTX) administration followed by vacuum aspiration or resectoscopic approach was reported, with an overview of literature. Eleven patients with CSP underwent a double-step treatment: systemic MTX therapy followed by vacuum aspiration or by resectoscopy, if the gestational sac was embedded deeply in myometrium. For CSP type 1, according to Delphi sonographic classification, with minor potentially risk of complications with a myometrial thickness >3.5 mm, we preferred to adopt vacuum aspiration, while type 2-3 of CSP and myometrial thickness ≤3.5mm were managed with resectoscopy., Results: The average gestational age was 59.1±7.22 days. On the seventh day after MTX administration, the serum β hCG levels decreased in 80% of all patients. After the MTX injection, the CSP mass did not disappear in any patient. MTX therapy was followed by vacuum aspiration in six and by resectoscopy in five cases. In one case bleeding was controlled by Foley balloon treated with vacuum. In type II-III, CSP was performed UAE (uterine artery embolization) followed by resectoscopy procedure., Conclusions: Compared with the results in previous studies, MTX administration followed by suction curettage was more effective than dilatation and curettage and systemic MTX in treatment of CSP. We consider very useful this procedure in case of slow absorption and when the camera was embedded deeply in myometrium (CSP2-3), because that hysteroscopy evaluation of uterine cavity under direct vision is highly accurate in identifying the real cleavage of the gestational camera. We have only used vacuum aspiration in CSP type 1 for minor risk of bleeding.

Objectives: to evaluate the effect of sublingual dexmedetomidine versus nasal dexmedetomidine plus remifentanil-propofol infusion pump in gynecological procedures. Methods: Uncontrolled, double-blind, prospective clinical trial. 68 patients with inclusion criteria were divided into 3 groups, group A [sublingual dexmedetomidine at 0.75 ug/kg], group B [nasal dexmedetomidine at 0.9 ug/kg] and group C [control] plus the addition of remifentanil and propofol by infusion pumps. Statistical analysis of qualitative variables with chisquare, quantitative variables with free distribution used Kruskal-Wallis and normal distribution Anova. Confidence level of 95% and margin of error of 9%. Results: age with a range of 30 to 32 years, the starting and maintenance dose of both remifentanil and propofol was halved compared to the control group, mainly in group A. With little variability in hemodynamic parameters without clinical repercussion. The most frequent adverse effects were respiratory depression in the control group, no analgesia was observed with the use of dexmedetomidine. And with a shorter stay in recovery rooms in patients who received nasal dexmedetomidine. Conclusions: sublingual administration is superior to nasal due to the lower requirement of propofol, less changes in mean blood pressure, with no adverse effects that can be managed, and with greater ease of administration. Although nasal administration produces a faster awakening and better control of heart rate. [ABSTRACT FROM AUTHOR]

Objective: To compare feasibility, efficacy and patient acceptability of manual vacuum aspiration with sublingual Misoprostol in early pregnancy loss. Study Design: Comparative prospective study. Place and Duration of Study: Gynecology and Obstetrics Department, Combined Military Hospital Okara Pakistan, from Aug 2019 to Apr 2020. Methodology: 200 Patients with early pregnancy loss (missed, incomplete abortion) at gestational age 6 to 12 weeks were randomly allocated to Manual vacuum aspiration (group A) and oral Misoprostol (group B) by lottery methods. Manual vacuum aspiration was done in the outpatient department. While in Group B, oral Misoprostol was given with a protocol 600 micro gram sublingual stat observe for 1 hour for any complication. Afterwards, they were given Misoprostol 600 micrograms sublingual, 3 hourly total of 2 doses. Patients from both groups were called for follow-up after one week. Results: Efficacy, feasibility and patient acceptability was 88%; p-value <0.001, 95%; p-value <0.001 and 97% respectively in manual vacuum aspiration group as compared to 64%, 68% and 70% in sublingual Misoprostol group. There were fewer systemic side effects and fewer visits in manual vacuum aspiration group 1 vs 3 in the sublingual Misoprostol group. Conclusion: Manual vacuum aspiration is more effective than Misoprostol as it has no systemic effects. Both options are cheap and can be achieved in outpatient settings. However, manual vacuum aspiration provides complete evacuation and is a good option for low resource settings and a developing country like Pakistan with frequent electricity disruptions. It offers a substantial saving on resources, cost and time. [ABSTRACT FROM AUTHOR]

Background: In Japan, dilatation & curettage (D&C) has been performed under general anesthesia as a surgery for an early pregnancy miscarriage for a long time. In 2016, manual vacuum aspiration (MVA) under general anesthesia was introduced at our hospital and has been used as a surgical treatment for first-trimester pregnancy miscarriage, with its utility to date being reported here. In July 2018, our hospital introduced the MVA procedure under local anesthesia. In this study, we evaluated the efficacy and safety of MVA under general and local anesthesia in first-trimester pregnancy miscarriage surgery in Japanese women. Methods: In this retrospective observational cohort study, we enrolled 322 pregnant women at less than 12 weeks of gestation, who underwent MVA surgery under local anesthesia (n = 166) or conventional general anesthesia (n = 156). The duration of surgery, blood loss volume, quantity of anesthesia, presence or absence of retained products of conception, and clinical complications were evaluated. In addition, the intraoperative pain and treatment satisfaction were assessed using the visual analog scale (VAS). Results: The duration of surgery was significantly shorter in the local anesthesia group. No significant differences were observed between both groups in terms of the blood loss volume and incidence of retained products of conception. In addition, no serious complications were observed in either group. No significant differences were noted between the two groups in the VAS scores for pain and treatment satisfaction. Conclusions: In this retrospective study, the use of MVA under local anesthesia for early pregnancy miscarriage surgery was found to be equally safe and effective when performed under conventional general anesthesia. This technique allowed the achievement of appropriate pain control with excellent patient satisfaction. [ABSTRACT FROM AUTHOR]

Objective: To compare immediate initiation with delayed initiation of medication abortion among patients with an undesired pregnancy of unknown location.Methods: This retrospective cohort study used electronic medical record data from the Planned Parenthood League of Massachusetts (2014-2019) for patients who requested medication abortion with a last menstrual period (LMP) of 42 days or less and pregnancy of unknown location (no gestational sac) on initial ultrasonogram. Clinicians could initiate medication abortion with mifepristone followed by misoprostol while simultaneously excluding ectopic pregnancy with serial serum human chorionic gonadotropin (hCG) testing (same-day-start group) or establish a diagnosis with serial hCG tests and repeat ultrasonogram before initiating treatment (delay-for-diagnosis group). We compared primary safety outcomes (time to diagnosis of pregnancy location [rule out ectopic], emergency department visits, adverse events, and nonadherence with follow-up) between groups. We also reported secondary efficacy outcomes: time to complete abortion, successful medication abortion (no uterine aspiration), and ongoing pregnancy.Results: Of 5,619 medication abortion visits for patients with an LMP of 42 days or less, 452 patients had pregnancy of unknown location (8.0%). Three patients underwent immediate uterine aspiration, 55 had same-day start, and 394 had delay for diagnosis. Thirty-one patients (7.9%), all in the delay-for-diagnosis group, were treated for ectopic pregnancy, including four that were ruptured. Among patients with no major ectopic pregnancy risk factors (n=432), same-day start had shorter time to diagnosis (median 5.0 days vs 9.0 days; P=.005), with no significant difference in emergency department visits (adjusted odds ratio [aOR] 0.90, 95% CI 0.43-1.88) or nonadherence with follow-up (aOR 0.92, 95% CI 0.39-2.15). Among patients who proceeded with abortion (n=270), same-day start had shorter time to complete abortion (median 5.0 days vs 19.0 days; P<.001). Of those who had medication abortion with known outcome (n=170), the rate of successful medication abortion was lower (85.4% vs 96.7%; P=.013) and the rate of ongoing pregnancy was higher (10.4% vs 2.5%; P=.041) among patients in the same-day-start group.Conclusion: In patients with undesired pregnancy of unknown location, immediate initiation of medication abortion is associated with more rapid exclusion of ectopic pregnancy and pregnancy termination but lower abortion efficacy. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of priming the uterine cervix before Manual Vaccum Aspiration (MVA) using 200 µg or 400 µg of vaginal misoprostol, inserted a mean time of 6 h before MVA in first trimester miscarriage.Study Design: Randomized, triple-blind, non-inferiority clinical trial. Patients between 18 and 50 years old, with a diagnosis of miscarriage, were eligible for the study. Patients were allocated to receive either 200 μg or 400 µg of misoprostol before the MVA. The primary outcome was the need to dilate the uterine cervix with mechanical dilators (Hegar dilators). As a secondary outcome, cervical dilatation ≥8 mm before the procedure was considered successful. A difference of <25% was considered as non-inferior.Results: Between December 21, 2016 and October 6, 2019, 269 women were screened. After screening, 105 and 106 women received 200 µg and 400 µg of misoprostol, respectively. Mechanical cervical dilatation was not necessary in 84.8% (95%CI 77% to 90%) and 96.2% (95%CI 91% to 99%), in the 200 µg and 400 µg groups, respectively [difference = 11.5% (95%CI 3.7% to 19.2%). Cervical dilatation of ≥8 mm was 52.4% (95%CI 42.9% to 61.7%) in the 200 µg misoprostol group, while in the 400 µg group was 71.7% (95%CI 62.5% to 79.4%) [difference = 19.3% (95%CI 6.5 to 32.2).Conclusion: After a mean time of 6 h, 200 µg of vaginal misoprostol is not inferior to 400 µg of misoprostol for cervical priming before MVA, in first trimester miscarriage. This non-inferiority was not observed when the ≥8 mm criterion was considered. [ABSTRACT FROM AUTHOR]

Objective: To determine if transdermal scopolamine is associated with decreased postoperative nausea and vomiting and shorter length of stay in the postoperative care unit among patients undergoing uterine aspiration for abortion or early pregnancy loss.Study Design: We conducted a retrospective cohort study at an integrated medical center that initiated a protocol to prescribe transdermal scopolamine to patients undergoing uterine aspiration under moderate sedation. We compared outcomes among patients who underwent uterine aspiration in 2017, before the institution enacted the protocol, with their counterparts in 2018, immediately after the institution instated the protocol. We reviewed patient charts for data on the postoperative length of stay, use of additional antiemetics, and a standardized clinician designated postoperative nausea and vomiting score. We analyzed outcomes by relevant demographic and clinical characteristics using chi-square or Fisher's exact tests for categorical variables and t tests for continuous variables.Results: The final sample included 386 patients; 228 who did not receive scopolamine and 158 who did. The cohorts were comparable in terms of demographic and clinical characteristics. The cohort that received transdermal scopolamine had a similar mean postoperative length of stay (75.4 ± 54.1 vs 71.1 ± 50.8 minutes; p = 0.43). There were no differences in the proportions of patients who were provided additional antiemetics (26 ± 11.4 vs 17 ± 10.8; p = 0.84) or had transient vomiting and retching (3 ± 1.9 vs 3 ± 1.3; p = 0.69) between the cohorts.Conclusion: We found no evidence that prophylactic transdermal scopolamine reduces postoperative nausea, vomiting, or length of stay among patients undergoing uterine aspiration.Implications: Among patients who underwent uterine aspiration under moderate sedation, use of prophylactic transdermal scopolamine was not associated with shorter postoperative length of stay or lesser use of antiemetics. Prophylactic transdermal scopolamine is not likely to be useful for patients undergoing uterine aspiration and could be an unnecessary cost. [ABSTRACT FROM AUTHOR]

Objective: To report a peculiar case of ultrasound diagnosis of spontaneous angular twin pregnancy. In literature, the terms "angular," "interstitial," and "cornual" pregnancies are often used inappropriately. Confusion in terminology may have contributed to difficulties in developing diagnostic ultrasound criteria to differentiate these ectopic pregnancies.Design: Case report.Setting: Obstetrics and Gynecology, Community Hospital "S. Maria delle Croci."Patient: A 28-year-old patient with a previous cesarean delivery was admitted to our hospital for management of a presumed angular ectopic pregnancy. Transvaginal ultrasound confirmed an ectopic dichorionic diamniotic twin pregnancy eccentrically located in the right superior angle of the uterine cavity: the first gestational sac appeared to have right angular implantation, whereas the second gestational sac seemed to deepen inside the myometrium, with a thin myometrial margin of only 3 mm.Interventions: After discussing the risks, the patient requested to proceed with termination. A single intramuscular injection of 75 mg of methotrexate was administered, followed by ultrasound-guided hysterosuction after 19 days due to severe vaginal bleeding.Main Outcome Measures: An early and accurate ultrasound diagnosis of a high-risk condition allowed for conservative medical treatment.Results: The serum beta-human chorionic gonadotropin levels progressively decreased. After 1 month, a clinical and ultrasound examination showed a regular endometrial line with a regular reappearance of menstrual bleeding.Conclusions: Although there are remarkable advances in ultrasound techniques, angular pregnancy remains a condition of difficult diagnosis and management; it is potentially dangerous and may lead to severe complications. An early and accurate diagnosis of this condition is necessary to avoid complications and individualize the subsequent management. [ABSTRACT FROM AUTHOR]

Introduction: single-dose of sublingual misoprostol 400mcg with the participant followed-up at the gynecology clinic one week after with an ultrasound scan for the completeness of the uterine evacuation. Objective: to compare the effectiveness of single-dose sublingual misoprostol to manual vacuum aspiration in the treatment of incomplete spontaneous abortion in Enugu, Nigeria. Methods: the primary outcome measure was the incidence of complete uterine evacuation (complete abortion) after one week of treatment while the secondary outcome measures included incidence, types, and tolerability of treatment side effects as well as participants' satisfaction with the treatment received. Results: two hundred and three participants who met the study criteria and completed the study were randomised into the intervention group (n=102) received single-dose sublingual misoprostol 400mcg and the control group (n= 101) received manual vacuum aspiration. Incidence of complete abortion was 86.3% for the misoprostol group and 100.0% for the control group, RR = 0.86, (CI 95%: 0.80 - 0.93), p <0.001. The most common side effect was abdominal pain with an incidence of 27.5% versus 48.55 for the misoprostol and control groups respectively (p = 0.002). Most participants in each group (81.1% versus 77.6% for the misoprostol and control groups respectively) considered the side effects as tolerable. The mean visual analogue scale score for maternal satisfaction was higher in the misoprostol group (86.7 ± 14.11) than the control group (81.36 ± 11.10), p < 0.001. Conclusion: the treatment of incomplete spontaneous abortion with single-dose sublingual misoprostol 400mcg produced a high rate of complete abortion among women in Enugu, Nigeria. Despite having a lower complete abortion rate, maternal satisfaction was higher when compared with women that had manual vacuum aspiration of the uterus. Trial registration: trial registration number - PACTR202009857889210, date of registration - September 23, 2020. Retrospectively registered. [ABSTRACT FROM AUTHOR]

Aim: In Japan, dilatation and curettage (D&C) is a common procedure for spontaneous miscarriage and induced abortion, and its safety has long been an issue. Electric vacuum aspiration (EVA) is also common, but manual vacuum aspiration (MVA) was introduced recently, with medical abortions using mifepristone or misoprostol which are not yet legally accepted. This nationwide retrospective study surveyed the surgical methods and complications associated with spontaneous miscarriage and induced abortion at less than 12 weeks of gestation in Japan to assess their safety, in comparison with a similar survey for induced abortions in 2012. Methods: Questionnaires were sent to 4176 facilities with a license for induced abortion surgeries in 2019. The questions included were the methods used, number of spontaneous miscarriages and induced abortions, and number of complications (uterine perforation, incomplete abortion, and gross bleeding requiring blood transfusion). Results: Responses were received from 1706 facilities (40.9%). Although EVA with sharp curettage was the most common surgical method, which was used for 11 953 spontaneous miscarriages (28.9%) and 24 045 induced abortions (37.3%), the most common surgical method per facility was D&C, and the rates of D&C for spontaneous miscarriages (38.4%) and induced abortions (44.7%) performed in general hospitals were significantly higher than those in clinics (24.1% and 22.0%, respectively). There was no significant difference in the complication incidence rate among surgical methods for spontaneous miscarriages. However, in induced abortion surgery, the total complication and incomplete abortion incidence rates for D&C were significantly higher than those for EVA without sharp curettage (47/15 162 [0.31%] vs. 29/18 693 [0.16%], p = 0.00362, 45/15 162 [0.30%] vs. 27/18 693 [0.14%], p = 0.00285, respectively). There was no significant difference in the complication incidence rate between MVA and other surgical methods for each abortion surgery. Conclusion: In Japan, especially in general hospitals, D&C is still widely used for miscarriage and induced abortion surgery. Its complication‐incidence rates significantly decreased compared with that of the nationwide survey in 2012, but were still significantly higher than EVA without sharp curettage. Few facilities used MVA, but its complication rate was comparable with those of other surgical methods. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the incidence, the risk factors, and the treatment outcomes of Non-tubal ectopic pregnancies (NTEP) treated in a tertiary care center., Material and Methods: A total of 110 NTEP cases treated between 2014 and 2019 were included in the retrospective study. The study cohort was divided into 6 groups according to the pregnancy localization: 87 cesarean scar pregnancies (CSPs), 7 ovarian pregnancies, 6 interstitial pregnancies, 4 rudimentary horn pregnancies, 4 abdominal pregnancies, and 2 cervical pregnancies. One woman rejected all treatment modalities. Demographic characteristics, treatment modalities, and outcomes of each group were evaluated., Results: In the study cohort, expectant management was performed in one (0.9%) woman. The methotrexate (MTX) treatment was administered in 29 (26.3%) women. Seventeen (15.4%) women underwent surgery, and 63 (57.2%) women underwent manual vacuum aspiration (MVA). A woman rejected all treatment modalities. Although 70.1% (n = 61) of CSPs were cured with MVA, 24.1% (n = 21) of them were treated with a single-dose MTX regimen in addition to MVA. The higher mean gestational sac size (33,9 ± 12,96 mm vs. 17,34 ± 9,87 mm), the higher mean gestational week (8,43 ± 1,16w vs. 6,66 ± 1,49w), the presence of fetal heartbeat (FHB) (90.5% vs. 26,2%) and the history of pelvic ınflammatory disease (PID) (38.1% vs. 6,6%) were found in the CSPs with MVA treatment failure (p < 0.05)., Conclusion: The management of NTEPs should be individualized according to the clinical and ultrasonographic findings. The size of the ectopic pregnancy mass, the gestational week, the presence of FHB, and the PID history were the predictive factors for the failure of MVA in CSP cases., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry., Objective: This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies., Study Design: We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions., Results: Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9)., Conclusion: A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)