O Papel Da Laparoscopia Diagnóstica Em Ginecologia

Laparoscopy is a diagnostic method that is currently becoming consolidated for therapeutic use. It consists of endoscopically viewing the abdominal cavity. The aim here was to evaluate the indications for diagnostic videolaparoscopy and the intraoperative findings in an endoscopic gynecology clinic at a tertiary-level hospital over the last five years. DESIGN AND SETTING: Retrospective descriptive study on all diagnostic videolaparoscopy procedures of the last five years carried out in the endoscopic gynecology clinic of a tertiary-level hospital. METHODS: The medical records of 618 women who underwent diagnostic laparoscopy between 2008 and 2012 were analyzed. The clinical characteristics of these women, the indications for videolaparoscopy and the intraoperative findings were evaluated. RESULTS: The women’s mean age was 32 ± 6.4 years. Most of the women had already undergone at least one previous operation (60%), which was most frequently a cesarean. The indications for performing videolaparoscopy were infertility in 57%, chronic pelvic pain in 27% and others (intrauterine device, adnexal tumor, ectopic pregnancy or pelvic inflammatory disease) in 16%. The main laparoscopic findings were tubal alterations in the group with infertility (59.78%) and peritoneal alterations in the group with chronic pelvic pain (43.54%). CONCLUSION: The main indications for videolaparoscopy in gynecology were infertility and chronic pelvic pain. However, in most procedures, no abnormalities justifying these complaints were found. © 2016, Associacao Paulista de Medicina. All rights reserved.1341707

Conservative Management Of Ectopic Pregnancy In Cesarean Scar: Case Report [tratamento Conservador Da Gravidez Ectópica Em Cicatriz De Cesárea: Relato De Caso]

Implantation of a pregnancy within a cesarean delivery scar is considered to be the rarest form of ectopic pregnancy, with a high morbidity and mortality. Pregnancy in a cesarean delivery scar may cause catastrophic complications which may result in hysterectomy and compromise the reproductive future of a woman. We report an ectopic pregnancy in cesarean scar case in a 28-year old pregnant woman that was treated with success with the association between three treatment modalities (methotrexate, uterine artery embolization and curettage) and preserve her fertility.355233237Fylstra, D.L., Pound-Chang, T., Miller, M.G., Cooper, A., Miler, K.M., Ectopic pregnancy within a cesarean delivery scar: A case report (2002) Am J Obstet Gynecol, 187 (2), pp. 302-304Bignardi, T., Condous, G., Transrectal ultrasound-guided surgical evacuation of cesarean scar ectopic pregnancy (2010) Ultrasound Obstet Gynecol, 35 (4), pp. 481-485Jurkovic, D., Hillaby, K., Woelfer, B., Lawrence, A., Salim, R., Elson, C.J., First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar (2003) Ultrasound Obstet Gynecol, 21 (3), pp. 220-227Seow, K.M., Huang, L.W., Lin, Y.H., Lin, M.Y., Tsai, Y.L., Hwang, J.L., Caesarean scar pregnancy: Issues in management (2004) Ultrasound Obstet Gynecol, 23 (3), pp. 247-253Herman, A., Weinraub, Z., Avrech, O., Maymon, R., Ron-El, R., Bukovsky, Y., Follow up and outcome of isthmic pregnancy located in a previous caesarean section scar (1995) Br J Obstet Gynaecol, 102 (10), pp. 839-841Litwicka, K., Greco, E., Caesarean scar pregnancy: A review of management options (2011) Curr Opin Obstet Gynecol, 23 (6), pp. 415-421Rotas, M.A., Haberman, S., Levgur, M., Cesarean scar ectopic pregnancies: Etiology, diagnosis, and management (2006) Obstet Gynecol, 107 (6), pp. 1373-1381Larsen, J.V., Solomon, M.H., Pregnancy in a uterine scar sacculus--an unusual cause of postabortal haemorrhage. A case report (1978) S Afr Med J, 53 (4), pp. 142-143Timor-Tritsch, I.E., Monteagudo, A., Unforeseen consequences of the increasing rate of cesarean deliveries: Early placenta accreta and cesarean scar pregnancy A review (2012) Am J Obstet Gynecol, 207 (1), pp. 14-29Agarwal, N., Shahid, A., Odejinmi, F., Caesarean scar pregnancy (CSP): A rare case of complete scar dehiscence due to scar ectopic pregnancy and its management (2013) Arch Gynecol Obstet, , Jan 5. [Epub ahead of printGodin, P.A., Bassil, S., Donnez, J., An ectopic pregnancy developing in a previous caesarian section scar (1997) Fertil Steril, 67 (2), pp. 398-400Arruda, M.S., Camargo Jr., H.S., Cesarean scar ectopic pregnancy: A case report] (2008) Rev Bras Ginecol Obstet, 30 (10), pp. 518-523Wang, S., Dong, Y., Meng, X., Intramural ectopic pregnancy: Treatment using uterine artery embolization (2013) J Minim Invasive Gynecol, 20 (2), pp. 241-243Seow, K.M., Wang, P.H., Huang, L.W., Hwang, J.L., Transvaginal sono-guided aspiration of gestational sac concurrent with a local methotrexate injection for the treatment of unruptured cesarean scar pregnancy (2013) Arch Gynecol Obstet, , Feb 27. [Epub ahead of print]Shen, L., Tan, A., Zhu, H., Guo, C., Liu, D., Huang, W., Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy (2012) Am J Obstet Gynecol, 207 (5), pp. e1-e6Maymon, R., Halperin, R., Mendlovic, S., Schneider, D., Herman, A., Ectopic pregnancies in a caesarean scar: Review of the medical approach to an iatrogenic complication (2004) Hum Reprod Update, 10 (6), pp. 515-523Li, N., Zhu, F., Fu, S., Shi, X., Transvaginal ultrasound-guided embryo aspiration plus local administration of low-dose methotrexate for caesarean scar pregnancy (2012) Ultrasound Med Biol, 38 (2), pp. 209-213de Vaate, A.J., Brolmann, H.A., van der Slikke, J.W., Wouters, M.G., Schats, R., Huirne, J.A., Therapeutic options of caesarean scar pregnancy: Case series and literature review (2010) J Clin Ultrasound, 38 (2), pp. 75-84Jiang, T., Liu, G., Huang, L., Ma, H., Zhang, S., Methotrexate therapy followed by suction curettage followed by Foley tamponade for caesarean scar pregnancy (2011) Eur J Obstet Gynecol Reprod Biol, 156 (2), pp. 209-211Le, A., Shan, L., Xiao, T., Zhuo, R., Xiong, H., Wang, Z., Transvaginal surgical treatment of cesarean scar ectopic pregnancy (2013) Arch Gynecol Obstet, 287 (4), pp. 791-796Shao, M.J., Hu, M.X., Hu, M., Temporary bilateral uterine artery occlusion combined with vasopressin in control of hemorrhage during laparoscopic management of cesarean scar pregnancies (2013) J Minim Invasive Gynecol, 20 (2), pp. 205-208Wu, X., Zhang, X., Zhu, J., Di, W., Caesarean scar pregnancy: Comparative efficacy and safety of treatment by uterine artery chemoembolization and systemic methotrexate injection (2012) Eur J Obstet Gynecol Reprod Biol, 161 (1), pp. 75-79Yang, X.Y., Yu, H., Li, K.M., Chu, Y.X., Zheng, A., Uterine artery embolisation combined with local methotrexate for treatment of caesarean scar pregnancy (2010) BJOG, 117 (8), pp. 990-996Lian, F., Wang, Y., Chen, W., Li, J., Zhan, Z., Ye, Y., Uterine artery embolization combined with local methotrexate and systemic methotrexate for treatment of cesarean scar pregnancy with different ultrasonographic pattern (2012) Cardiovasc Intervent Radiol, 35 (2), pp. 286-291Zhang, B., Jiang, Z.B., Huang, M.S., Guan, S.H., Zhu, K.S., Qian, J.S., Uterine artery embolization combined with methotrexate in the treatment of cesarean scar pregnancy: Results of a case series and review of the literature (2012) J Vasc Interv Radiol, 23 (12), pp. 1582-1588Yin, X., Su, S., Dong, B., Ban, Y., Li, C., Sun, B., Angiographic uterine artery chemoembolization followed by vacuum aspiration: An efficient and safe treatment for managing complicated cesarean scar pregnancy (2012) Arch Gynecol Obstet, 285 (5), pp. 1313-1318Pang, Y.P., Tan, W.C., Yong, T.T., Koh, P.K., Tan, H.K., Ho, T.H., Caesarean section scar pregnancy: A case series at a single tertiary centre (2012) Singapore Med J, 53 (10), pp. 638-642Zhang, Y., Gu, Y., Wang, J.M., Li, Y., Analysis of cases with cesarean scar pregnancy (2013) J Obstet Gynaecol Res, 39 (1), pp. 195-20

Prevalência De Fatores Associados à Infertilidade Em Mulheres Inférteis Submetidas à Laparoscopia Diagnóstica

To evaluate the role of laparoscopy in the investigation of infertility at the University of Campinas in the last five years. Methods Retrospective descriptive study with all diagnostic laparoscopy in the last five years made in endoscopic gynecology clinic of the tertiary hospital. 353 medical records of women with infertility undergoing diagnostic laparoscopy between the years 2008 to 2012 were analyzed the clinical characteristics of these women and the indications of laparoscopy and intraoperative findings were evaluated. Descriptive analysis (frequency, mean and standard deviation) was performed for categorical variables. To evaluate the association between the variables, we used the Kruskal Wallis test. Results The women were on average 32 ± 4.4 years. Laparoscopy found 52.98% of tubal alterations, 17.84% of endometriosis and 11.33% of adhesions. Almost 18% of tests did not show any change. The hysterosalpingography had a sensitivity of 84.61% and specificity of 32.58% compared to laparoscopy. Infertile women have a higher risk for tubal changes. Conclusion Tubal alterations are still the leading cause of infertility. Laparoscopy appears as a better technique hysterosalpingography for detecting tubal alterations, in addition to be able to detect changes in other organs that can cause infertility. © 2016 Sociedade Brasileira de Reprodução Humana31315916

Comparative Study Of Transvaginal Sonography And Outpatient Hysteroscopy For The Detection Of Intrauterine Diseases [comparação Do Ultra-som Transvaginal E Da Histeroscopia Ambulatorial No Diagnóstico Das Doenças Intra-uterinas]

Introduction: Intrauterine diseases are common morbid disorders. Endometrial and endocervical polyps, myomas, synechiae, uterine malformations, endometrial hyperplasia and endometrial cancer are cited among intrauterine pathology. The investigations using transvaginal sonography and outpatient hysteroscopy had been a gold standard. Transvaginal sonography shows endometrial thickness and heterogeneous variations within the echogenecity of the endometrium uterine pathology. Transvaginal sonography is easy to apply for evaluation of intrauterine pathology and it has high sensitivy to diagnostic for intrauterine disorders. Hysteroscopy was used the gold standard control. It permited the better identification of intrauterine pathology but the histologic examination has been used for definitive diagnostic. Difficulty apprenticeship this technique had very decrease your access. Objectives: To evaluate the efficiency of transvaginal ultrasonography and outpatient hysteroscopy in the diagnosis of intrauterine pathology. Subjects and methods: The study conducted was a retrospective diagnostic-type test. They involved a total of 469 women underwent diagnostic hysteroscopy in 2006 in Campinas University. Seventy-nine women were excluded due to lack of ultrasound results in their medical charts. One-hundred and forty-seven premenopausal women and two-hundred and forty-three postmrnopausal women. For statistical analysis, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy. The gold standard of the ultrasonography was the hysteroscopy and the gold standard of the hysteroscopy was the endometrium biopsy. Results: The mean age of postmenopausal women was 61±9.4 years. We observed 6.6% of endometrial hyperplasia and cancer and 54% of endometrial polyps. Ultrasonography had a sensitivity of 95.6%, a specificity of 7.4% and an accuracy of 53.7%, while hysteroscopy had a sensitivity of 95.7%, a specificity of 83% and an accuracy of 88.7%. The mean age of premenopausal women was 40±8.2 years. Endometrial cancer was not observed and two cases of endometrial hyperplasia were found. We observed 34% of endometrial polyps. Sensibility was 52.9%, specificity was 68.4% and the accuracy was 61.2% for polyps on ultrasonography while in hysteroscopy was 78.8%, 67.6% and 73.1% respectively. For myoma, sensitivily was 70.6% and 64.3%, specificity was 44.3% and 98.1% and accuracy was 63.3% and 91.2% in ultrasonography and hysteroscopy respectively. Conclusion: Hysteroscopy had better diagnostic accuracy than ultrasonography for the detection of intrauterine pathology.24SUPPL.26570Whitehead, M.I., Spencer, C.P., Endometrial assessment revisited (1999) Br Obstet Gynecol, 106, pp. 623-632Witt, B.R., Pelvic factors and infertility (1991) Infertil Reprod Med Clin North Am, 2, p. 371Batzer, F.R., Abnormal uterine bleeding: Imaging techniques for evaluation of the uterine cavity and endometrium before minimally invasive surgery - the case for transvaginal ultrasonography (2007) J Minimally Invasive Gynecol, 14, pp. 9-11Cepni, I., Ocal, P., Erkan, S., Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluationof uterine cavity pathologies (2005) Australian New Zealand J Obstet Gynecol, 45, pp. 30-35Goldastein, S.R., Zelster, I., Horan, C.K., Snyder, J.R., Schwartz, L.B., Ultrasonography based triage for perimenopausal patients with abnormal uterine bleending (1997) Am J Obstet Gynecol, 177, pp. 102-108Dijkhuizen, F.P.H.L.J., Brolman, H.A.M., Potters, A.E., Bongers, M.Y., Heintz, A.P.M., The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities (1996) Obstet Gynecol, 87, pp. 345-349Kremer, C., Duffy, S., Moroney, M., Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: Randomized, controlled trial (2001) BMJ, 320, pp. 279-282Alborzi, S., Parsanezhad, M.E., Mahmoodian, S., Sonohysterography versus transvaginal sonography for screening of patients with abnormal uterine bleeding (2007) Int J Gyneco Obstet, 96, pp. 20-23Makris, N., Kalmantis, K., Skartados, N., Papadimitriou, A., Mantzaris, G., Antsaklis, A., Three-dimensional hysterosonography versus hysteroscopy for the detection of intracavitary uterine abnormalities (2007) Int J Gynecol Obstet, 97, pp. 6-9Gimpelson, R.J., Rappold, R.O., A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage (1988) Am J Obstet Gynecol, 158, pp. 489-492Bradley, L.D., Falcone, T., Magen, A.B., Radiographic imaging techniques for the diagnosis of abnormal uterine bleeding (2000) Obstet Gnecol Clin North Am, 27, pp. 245-246Bradley, L.D., Pasqualatto, E.B., Pricell, M.H., Hysteroscopic management endometrial polyps (2000) Obstet Gynecol, 4, pp. S23Gumus, I.I., Keskin, E.A., Kiliç, E., Aker, A., Kalalr, H., Turhan, N.O., Diagnostic value of hysteroscopy end hysterosonography in endometrial abnormalities in asymptomatic postmenopausal women (2008) Arch Gynecol Obstet, 278, pp. 241-244Timmermans, A., Gerritse, M.B.E., Opmeer, B.C., Jansen, F.W., Mol, B.W.J., Veersema, S., Diagnostic accuracy of endometrial thickness to exclude polyps in women with postmenopausal bleeding (2008) J Clinical Ultrasound, 36, pp. 286-290Tinelli, R., Tinelli, F.G., Cicinelli, E., Malvasi, A., Tinelli, A., The role of hysteroscopy with eye-directed biopsy in postmenopausal women with uterine bleeding and endometrial atrophy (2008) Menopause, 15, pp. 737-742Loverro, G., Bettochi, S., Cormio, G., Transvaginal sonography and hysteroscopy in postmenopausal uterine bleeding (1999) Maturitas, 33, pp. 139-144Garuti, G., Sambruni, I., Cellani, F., Garzia, D., Alleva, P., Luerti, M., Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding (1999) Int J Gynecol Obstet, 65, pp. 25-33Kelekci, S., Kaya, E., Alan, M., Comparison of trnsvaginal sonography, saline infusion sonography, and office hysteroscopy in reproductive-aged women with or without abnormal uterine bleeding (2005) Fertil Steril, 84, pp. 682-686Towbin, N.A., Gviazda, I.M., March, C.M., Office hysteroscopy versus transvaginal ultrasonographyin the evaluation of patients with excessive uterine bleeding (1996) Am J Obstet Gynecol, 174, pp. 1678-1682Angioni, S., Loddo, A., Milano, F., Piras, B., Minerba, L., Melis, G.B., Detectionod benign intracavitary lesions in postmenopausal women with abnormal uterine bleeding: A prospective comparative study on outpatient hysteroscopy and blind biopsy (2008) J Minimally Invasive Gynecol, 15, pp. 87-91Machtinger, R., Korach, J., Padoa, A., Transvaginal ultrasound and diagnostic hysteroscopyas a predictor of endometrial polyps: Risk factors for premalignancy and malignancy (2005) Int J Gynecol Cancer, 15, pp. 325-32

Accelerated surgery versus standard care in hip fracture (HIP ATTACK) : an international, randomised, controlled trial

Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4\u20139) in the accelerated-surgery group and 24 h (10\u201342) in the standard-care group (p<0\ub70001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0\ub791 (95% CI 0\ub772 to 1\ub714) and absolute risk reduction (ARR) of 1% ( 121 to 3; p=0\ub740). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0\ub797 (0\ub783 to 1\ub713) and an ARR of 1% ( 122 to 4; p=0\ub771). Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. Funding: Canadian Institutes of Health Research