Placenta accreta:adherent placenta due to Asherman syndrome

It is important to be aware of the risk of abnormally invasive placenta in patients with a history of Asherman syndrome and uterine scarring. A prenatal diagnosis by ultrasonography is useful when planning of mode of delivery

Initial laparoscopic access in postmenopausal women: a preliminary prospective study.

OBJECTIVE: Estrogen loss at menopause has a profound influence on skin, with postmenopausal atrophy and loss of tone and elasticity. Because more than 50% of major laparoscopic complications occur during initial entry under the abdominal skin, the efficacy and the safety of two laparoscopic access techniques were compared in postmenopausal women. METHODS: One hundred eighty-six postmenopausal women underwent laparoscopic surgery for simple ovarian cysts: 89 were assigned to direct optical access (DOA), abdominal entry (group I), and 97 to the classic closed Veress needle approach, pneumoperitoneum, and trocar entry (group II). The following parameters were compared: time needed for entry into the abdomen, occurrence of vascular and/or bowel injury, and blood loss. Results were analyzed using SAS software, considering P value less than 0.05 as significant. RESULTS: No statistically significant differences were observed in the occurrence of major vascular and/or bowel injury between the two techniques (P > 0.05), whereas time for abdominal entry was significantly reduced in the DOA group, as well as the occurrence of minor vascular injuries (P < 0.05). CONCLUSIONS: Results of this preliminary comparison on the DOA and the Veress methods, commonly used by gynecologists, suggest that the visual entry system offers a statistical advantage over the closed Veress needle approach, in terms of time saving and limiting minor vascular injuries, thus enabling a safe and fast visually guided entry in postmenopausal women

Initial Laparoscopic Access in Postmenopausal Women: A Preliminary Prospective Study.

Hypoestrogenism in postmenopausal women results in skin atrophy with a decrease in both elasticity and skin thickness. The fragility of the skin in aging women may be responsible for the reported 50% or more increase in major laparoscopic complications during the initial entry into the female abdomen. Several first-entry techniques in laparos- copy have been investigated to minimize entry-related complications. The Veress needle approach is the standard method used by most gynecologists. A promising new method is the direct optical access (DOA) which uses optically-guided trocars to provide visual guidance during entry. These 2 techniques have not been compared. The aim of this prospective randomized study was to evaluate the efficacy and safety of these 2 methods in postmenopausal women. The study was conducted at multiple European gynecology centers between 2004 and 2008. A total of 186 postmenopausal women scheduled to undergo laparoscopy for simple, persistent postmenopausal ovarian cysts were randomized to 2 groups: group I (n = 89) was assigned to surgical entry using DOA, and group 2 (n = 97) was assigned to entry using the Veress needle method. The 2 procedures were compared for the following parameters: the time needed for achieve adequate abdominal access, the occurrence of major and minor vascular and bowel injuries, and blood loss during laparoscopic access. The time needed to establish adequate abdominal access was significantly reduced in the DOA access group compared to the Veress group (65.7 ± 11.9 vs. 192.8 ± 5.6 minutes; P < 0.0001), but there were no significant differences between the two groups in the occurrence of major vascular and/or bowel injuries (P = NS). Although fewer minor vascular injuries were found with DOA method than the Veress technique (1 versus 3), the difference was not statistically significant. The findings of this small preliminary study suggest that use of the DOA technique may be a safe and less time-consuming approach to abdominal entry in postmenopausal women and may avoid the risks of blind access laparoscopy

Goserelin acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: a 3-year follow-up evaluation.

OBJECTIVE: To report the results of a 3-year follow-up evaluation of a trial comparing goserelin acetate depot injections with sham injections before endometrial ablation for the treatment of dysfunctional uterine bleeding (DUB). DESIGN: Prospective, randomized, double-blind, parallel-group study. SETTING: Thirty-seven centers in 12 countries. PATIENT(S): Three-hundred and fifty-eight premenopausal women aged over 30 years with DUB. INTERVENTION(S): Goserelin acetate (3.6 mg depot) every 28 days for 8 weeks, or sham depot every 28 days for 8 weeks, with endometrial ablation 6 weeks +/- 3 days after the first depot injection (i.e., when the endometrium is at its thinnest). The follow-up continued for 3 years. MAIN OUTCOME MEASURE(S): At the 3-year follow-up, bleeding in the previous 3 months and need for surgical intervention were recorded. RESULT(S): At 3 years, amenorrhea rates were 21% in the goserelin acetate group and 14% in the control group (estimated odds ratio, 1.8; 95% CI, 0.98-3.25; P=.0571). The surgical intervention rate (since the original procedure) was low and did not differ significantly between groups. For hysterectomy, it was 21% for the goserelin acetate group and 15% for the control group. For repeat ablations, it was 5.6% for the goserelin acetate group and 2.1% for the control group. CONCLUSION(S): Prethinning with goserelin acetate before endometrial ablation resulted in higher long-term amenorrhea rates than ablation without prethinning