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Hysteroscopic management of life-threatening post-abortion hemorrhage
European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 109–111
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTERS TO THE EDITOR—BRIEF COMMUNICATIONS Hysteroscopic management of life-threatening post-abortion hemorrhage
Dear Editors, The management of Post Abortion Hemorrhage (PAH) is based on uterotonic medications, endometrial curettage, endometrial tamponade, uterine artery embolization, hypogastric artery ligation or save-life hysterectomy. We report on clinical outcomes of life-threatening PAH managed successfully at our department from May 2012 to January 2015 by emergency hysteroscopy surgery. Three patients were admitted for medical therapy with vaginal prostaglandins, for viable pregnancy termination at 20 weeks in one case and first trimester missed abortion in two women. Two patients were readmitted because of secondary PAH and in 1 patient primary PAH occurred after 3 h from the therapy started. Heavy uterine bleeding with hemorrhagic shock occurred in all patients (Table 1). Ultrasound examination found an endometrial mass highly vascularised [1], consistent with Retained Products of Conception (RPOC) in patients 1 and 2; in patient 3 a mass with a collapsed gestational sac was found at the level of uterine isthmus. Under general anesthesia we used a 27Fr resectoscope fitted with a bipolar loop, connected to the Versapoint Bipolar System generator (Gynecare, Ethicon Inc., Menlo Park CA) set at 160 W. Continuous flow of 450 ml/min of saline was delivered as distension medium at 80 mm/Hg working pressure. Pressure was increased to 100–120 mm/Hg when resulted insufficient in
maintaining uterine distension, due to fluid leakage between the sheath of hysteroscope and endocervix. After clearance of blood clots, we identified the uterine fundus and tubal ostia landmarks. Progressing outward with the hysteroscope, the topography and boundaries of residual placenta implantation were identified; in patients 1 and 2 we found an endometrial mass consistent with RPOC caused by an abnormally adherent placenta [2]. In the patient 3 a low-lying implantation extended to the cesarean scar was found (type 1 CSP) [3]. Hysteroscopy removal used the cold loop to separate placental tissue from decidua and underlying myometrium at implantation site; the electrified loop was used to slice the mass projecting within endometrial cavity. By deepening the resection, necrotic tissue mixed with thrombosed and bleeding placental vessels were found. To maintain visualization of the surgical field, a frequent use of coagulating current achieved hemostasis. In patients 1 and 2 the attempt to separate residual placenta from myometrium by cold-loop was hampered by the lack of cleavage plane. Beside myometrium, firm fibrous tissue and thrombosed utero-placental vessels were found embedded within inner myometrial fibers. Combining cold separation and careful electrosurgical slicing, the myometrial placental bed was cleared. In patient 3 a maintained cleavage plane allowed a blunt separation of placenta. The main technical difficulty was represented by the continuous balance between the saline inflow and outflow to obtain an endouterine clearance and a visceral distension enabling a satisfactory visualization of the surgical field. In all patients a 3 ways urologic balloon catheter was inflated within the uterine cavity and 0.4 mg of methylergometrine was administered. All patients received blood transfusion and were
Table 1 Population characteristics. Patient 1
Patient 2
Patient 3
Age (years) Parity Obstetric hystory
36 G0P0 –
Gestational age Cause of pregnancy termination Medical therapy for pregnancy termination Type of PAH Hemoglobin before intervention Beta-HCG before intervention Estimated blood loss Required blood derivates transfusions Hemoglobin levels at discharge Operating times Deficit of saline Hysteroscopy diagnosis
20 weeks Fetal omphalocele Vaginal misoprostol 400 mgc every 3 h to 3 administrations Secondary (23 days) 7.4 gr/dl 4 mIU/ml – 5U PRBC 1U FFP 9.9 gr/dl 45 min 300 ml Adherent placenta
37 G3P2 Two term vaginal birth, one D&C due to miscarriage 9 weeks Missed abortion Vaginal gemeprost, 1 mg every 3 h to 5 administrations Secondary (18 days) 6.0 gr/dl 301 mIU/ml – 5U PRBC 1U FFP 10.2 gr/dl 40 min 250 ml Adherent placenta
19 G1P1 One cesarean delivery due to breech presentation 8 weeks Missed abortion Vaginal gemeprost, 1 mg every 3 h to 5 administrations Primary (3 h) 6.5 gr/dl – 1800 ml 4U PRBC 1U FFP 9.0 gr/dl 32 min 400 ml Type 1 CSP
D&C: uterine dilatation and curettage, PAH: post-abortion hemorrhage, PRBC: packed red blood cells, FFP: fresh frozen plasma, CSP: cesarean scar pregnancy.
0301-2115/ã 2016 Elsevier Ireland Ltd. All rights reserved.
110
Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 109–111
admitted to the intensive care unit. An uneventful postoperative period followed, the balloon catheters were removed after 24 h and all patients discharged within 72 h. In patients 1 and 2 pathologic examination reported: “Decidual tissue with chorionic villi,extensive necrosis and myometrial fragments with inflammation and interstitial cytotrophoblastic cells”. In patient 3 “Hydropic villous trophoblast, decidual tissue and embryonic tissue” was found. Neither further intervention nor late complications occurred. Office hysteroscopy follow-up showed normal endometrial cavities in patients 1 and 2. Patient 3 was lost to follow-up. In clinically stable patients, hysteroscopy removal of RPOC, accreta and CSP was experienced as reliable. In our cases, the focal nature of pathology responsible for severe hemorrhage and the quick identification of its landmarks, represented essential assumptions to pursue a hysteroscopic treatment in severely ill patients. Hysteroscopy is usually not indicated in patients with ongoing severe uterine bleeding, due to the assumption that an impaired visualization hampers a safe and effective surgery. On our knowledge this is the first report suggesting a possible therapeutic role for resectoscopic surgery in the management of PAH caused by abnormal placentation. Nevertheless, this management necessitates continuous availability of hysteroscopy set-up and an experienced team. An emergency open surgery must be available at any time. References [1] Kamaya A, Petrovitch I, Chen B, Frederick CE, Jeffrey RB. Retained products of conception: spectrum of color Doppler findings. J Ultrasound Med 2009;28:1031–41. [2] Nisolle M, Delbeque K, Perrier D’Hauterive S, Firquet A, Chantraine F. Hysteroscopic resection of abnormally invasive placenta residuals. Acta Obstet Gynecol Scand 2013;92:451–6. [3] Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2000;21:592–3.
Stefania Calabrese* Giancarlo Garuti ASST Lodi, Dept. of Obstetrics and Gynecology, Via Savoia 1, Lodi, Italy * Corresponding author. E-mail address: [email protected] (S. Calabrese). Received 4 August 2016 http://dx.doi.org/10.1016/j.ejogrb.2016.10.027
Spontaneous resolution of mirror syndrome following fetal interventions for fetal anemia as a consequence of twin to twin transfusion syndrome
Dear Editor, We report the case of a 36-year-old G1P0 patient who was transferred to Texas Children’s Fetal Center at 21 weeks and 5 days of gestation for evaluation of twin to twin transfusion syndrome (TTTS). Upon arrival, she was contracting every 15–20 min. Ultrasound examination revealed monochorionic diamniotic twins with findings consistent with Quintero stage II TTTS [1] with marked polyhydramnios in the recipient (deepest vertical pocket [DVP] 14.5 cm). Doppler assessment was within normal limits in
both donor and recipient twins. The medical and past history was unremarkable apart from history of stage IV endometriosis. The patient had extensive counselling and she elected to proceed with fetoscopic directed laser photocoagulation of the placental anastomoses. The procedure was uncomplicated and complete “solomonization” was achieved [2]. The patient was discharged on the second postoperative day with normal amniotic fluid in both sacs (DVP 5.2 cm in the ex-recipient and 3.2 cm in the ex-donor). The ex-donor had a visible urinary bladder but showed signs of fetal hydrops (ascites and skin edema). Doppler evaluation of middle cerebral artery (MCA) was suggestive of fetal anemia in the ex-donor twin (MCA peak systolic velocity [PSV] 1.54 MoM). A septostomy was also noted. On post-operative day#3, the patient was readmitted to the hospital because of moderate skin edema in her lower extremities and significant vulvar edema. Her blood pressure was normal and deep tendon reflexes were brisk. Labs showed elevated liver enzymes (AST 137 U/L and ALT 96 U/L) but no proteinuria. A diagnosis of Mirror Syndrome was made on the basis of moderate maternal edema and fetal hydrops. Repeat ultrasound showed progression of the fetal hydrops with worsening of the anemia in the ex-donor twin (MCA PSV 1.77 MoM) without change in the exrecipient (MCA-PSV 1.18 MoM), excluding twin anemia polycythemia sequence (TAPS) [3]. A decision was made for intrauterine blood transfusion of the ex-donor. After extensive counselling, the patient elected to proceed with intrauterine transfusion. At the time of procedure, an intraperitoneal approach was chosen due to limited sonographic imaging due to significant chorioamniotic separation which was likely related to the recent laser procedure and close location of both umbilical cords. Nine ml of donor red blood cells were transfused into the peritoneal cavity of the ex-donor twin. Detailed ultrasound evaluation the following day revealed resolution of hydrops and marked improvement in MCA-PSV (1.3 MoM). The fetal ascites completely resolved following intraperitoneal transfusion. Resolution of fetal hydrops was followed by gradual improvement of the maternal Mirror Syndrome with disappearance of maternal edema and decrease of the liver enzymes levels over 5 days. At 27 weeks and 1 day, the patient had preterm premature rupture of membranes, went into labor and delivered two live born male infants who had uncomplicated NICU admissions for prematurity. Both boys are doing well as of their 4 month followup visit. Mirror Syndrome (or Ballantyne Syndrome) is a rare condition in which the mother mimics the hydropic fetus by developing generalized edema. Beside edema, the syndrome is frequently associated with pre-eclampsia or hypertension, proteinuria, pulmonary edema, high perinatal mortality and maternal morbidity [4]. Although spontaneous resolution of Mirror Syndrome has been rarely reported with some cases of hydrops secondary to parvovirus infection [5] and fetal demise [6], most cases require immediate delivery to treat the condition and prevent serious maternal morbidity and mortality [7,8]. Interestingly in our case, the Mirror Syndrome resolved following intrauterine transfusion for fetal anemia and hydrops that followed laser ablation for treatment of TTTS. The ex-donor required only one intrauterine blood transfusion presumably because the disease process was stopped by laser ablation of the communicating anastomoses. This case report adds to the literature by providing additional evidence that Mirror Syndrome may be resolved by correcting the underlying insult, and that in the absence of unmanageable hypertension or other complication of preeclampsia, immediate delivery is not always necessary.
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTERS TO THE EDITOR—BRIEF COMMUNICATIONS Hysteroscopic management of life-threatening post-abortion hemorrhage
Dear Editors, The management of Post Abortion Hemorrhage (PAH) is based on uterotonic medications, endometrial curettage, endometrial tamponade, uterine artery embolization, hypogastric artery ligation or save-life hysterectomy. We report on clinical outcomes of life-threatening PAH managed successfully at our department from May 2012 to January 2015 by emergency hysteroscopy surgery. Three patients were admitted for medical therapy with vaginal prostaglandins, for viable pregnancy termination at 20 weeks in one case and first trimester missed abortion in two women. Two patients were readmitted because of secondary PAH and in 1 patient primary PAH occurred after 3 h from the therapy started. Heavy uterine bleeding with hemorrhagic shock occurred in all patients (Table 1). Ultrasound examination found an endometrial mass highly vascularised [1], consistent with Retained Products of Conception (RPOC) in patients 1 and 2; in patient 3 a mass with a collapsed gestational sac was found at the level of uterine isthmus. Under general anesthesia we used a 27Fr resectoscope fitted with a bipolar loop, connected to the Versapoint Bipolar System generator (Gynecare, Ethicon Inc., Menlo Park CA) set at 160 W. Continuous flow of 450 ml/min of saline was delivered as distension medium at 80 mm/Hg working pressure. Pressure was increased to 100–120 mm/Hg when resulted insufficient in
maintaining uterine distension, due to fluid leakage between the sheath of hysteroscope and endocervix. After clearance of blood clots, we identified the uterine fundus and tubal ostia landmarks. Progressing outward with the hysteroscope, the topography and boundaries of residual placenta implantation were identified; in patients 1 and 2 we found an endometrial mass consistent with RPOC caused by an abnormally adherent placenta [2]. In the patient 3 a low-lying implantation extended to the cesarean scar was found (type 1 CSP) [3]. Hysteroscopy removal used the cold loop to separate placental tissue from decidua and underlying myometrium at implantation site; the electrified loop was used to slice the mass projecting within endometrial cavity. By deepening the resection, necrotic tissue mixed with thrombosed and bleeding placental vessels were found. To maintain visualization of the surgical field, a frequent use of coagulating current achieved hemostasis. In patients 1 and 2 the attempt to separate residual placenta from myometrium by cold-loop was hampered by the lack of cleavage plane. Beside myometrium, firm fibrous tissue and thrombosed utero-placental vessels were found embedded within inner myometrial fibers. Combining cold separation and careful electrosurgical slicing, the myometrial placental bed was cleared. In patient 3 a maintained cleavage plane allowed a blunt separation of placenta. The main technical difficulty was represented by the continuous balance between the saline inflow and outflow to obtain an endouterine clearance and a visceral distension enabling a satisfactory visualization of the surgical field. In all patients a 3 ways urologic balloon catheter was inflated within the uterine cavity and 0.4 mg of methylergometrine was administered. All patients received blood transfusion and were
Table 1 Population characteristics. Patient 1
Patient 2
Patient 3
Age (years) Parity Obstetric hystory
36 G0P0 –
Gestational age Cause of pregnancy termination Medical therapy for pregnancy termination Type of PAH Hemoglobin before intervention Beta-HCG before intervention Estimated blood loss Required blood derivates transfusions Hemoglobin levels at discharge Operating times Deficit of saline Hysteroscopy diagnosis
20 weeks Fetal omphalocele Vaginal misoprostol 400 mgc every 3 h to 3 administrations Secondary (23 days) 7.4 gr/dl 4 mIU/ml – 5U PRBC 1U FFP 9.9 gr/dl 45 min 300 ml Adherent placenta
37 G3P2 Two term vaginal birth, one D&C due to miscarriage 9 weeks Missed abortion Vaginal gemeprost, 1 mg every 3 h to 5 administrations Secondary (18 days) 6.0 gr/dl 301 mIU/ml – 5U PRBC 1U FFP 10.2 gr/dl 40 min 250 ml Adherent placenta
19 G1P1 One cesarean delivery due to breech presentation 8 weeks Missed abortion Vaginal gemeprost, 1 mg every 3 h to 5 administrations Primary (3 h) 6.5 gr/dl – 1800 ml 4U PRBC 1U FFP 9.0 gr/dl 32 min 400 ml Type 1 CSP
D&C: uterine dilatation and curettage, PAH: post-abortion hemorrhage, PRBC: packed red blood cells, FFP: fresh frozen plasma, CSP: cesarean scar pregnancy.
0301-2115/ã 2016 Elsevier Ireland Ltd. All rights reserved.
110
Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 208 (2017) 109–111
admitted to the intensive care unit. An uneventful postoperative period followed, the balloon catheters were removed after 24 h and all patients discharged within 72 h. In patients 1 and 2 pathologic examination reported: “Decidual tissue with chorionic villi,extensive necrosis and myometrial fragments with inflammation and interstitial cytotrophoblastic cells”. In patient 3 “Hydropic villous trophoblast, decidual tissue and embryonic tissue” was found. Neither further intervention nor late complications occurred. Office hysteroscopy follow-up showed normal endometrial cavities in patients 1 and 2. Patient 3 was lost to follow-up. In clinically stable patients, hysteroscopy removal of RPOC, accreta and CSP was experienced as reliable. In our cases, the focal nature of pathology responsible for severe hemorrhage and the quick identification of its landmarks, represented essential assumptions to pursue a hysteroscopic treatment in severely ill patients. Hysteroscopy is usually not indicated in patients with ongoing severe uterine bleeding, due to the assumption that an impaired visualization hampers a safe and effective surgery. On our knowledge this is the first report suggesting a possible therapeutic role for resectoscopic surgery in the management of PAH caused by abnormal placentation. Nevertheless, this management necessitates continuous availability of hysteroscopy set-up and an experienced team. An emergency open surgery must be available at any time. References [1] Kamaya A, Petrovitch I, Chen B, Frederick CE, Jeffrey RB. Retained products of conception: spectrum of color Doppler findings. J Ultrasound Med 2009;28:1031–41. [2] Nisolle M, Delbeque K, Perrier D’Hauterive S, Firquet A, Chantraine F. Hysteroscopic resection of abnormally invasive placenta residuals. Acta Obstet Gynecol Scand 2013;92:451–6. [3] Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2000;21:592–3.
Stefania Calabrese* Giancarlo Garuti ASST Lodi, Dept. of Obstetrics and Gynecology, Via Savoia 1, Lodi, Italy * Corresponding author. E-mail address: [email protected] (S. Calabrese). Received 4 August 2016 http://dx.doi.org/10.1016/j.ejogrb.2016.10.027
Spontaneous resolution of mirror syndrome following fetal interventions for fetal anemia as a consequence of twin to twin transfusion syndrome
Dear Editor, We report the case of a 36-year-old G1P0 patient who was transferred to Texas Children’s Fetal Center at 21 weeks and 5 days of gestation for evaluation of twin to twin transfusion syndrome (TTTS). Upon arrival, she was contracting every 15–20 min. Ultrasound examination revealed monochorionic diamniotic twins with findings consistent with Quintero stage II TTTS [1] with marked polyhydramnios in the recipient (deepest vertical pocket [DVP] 14.5 cm). Doppler assessment was within normal limits in
both donor and recipient twins. The medical and past history was unremarkable apart from history of stage IV endometriosis. The patient had extensive counselling and she elected to proceed with fetoscopic directed laser photocoagulation of the placental anastomoses. The procedure was uncomplicated and complete “solomonization” was achieved [2]. The patient was discharged on the second postoperative day with normal amniotic fluid in both sacs (DVP 5.2 cm in the ex-recipient and 3.2 cm in the ex-donor). The ex-donor had a visible urinary bladder but showed signs of fetal hydrops (ascites and skin edema). Doppler evaluation of middle cerebral artery (MCA) was suggestive of fetal anemia in the ex-donor twin (MCA peak systolic velocity [PSV] 1.54 MoM). A septostomy was also noted. On post-operative day#3, the patient was readmitted to the hospital because of moderate skin edema in her lower extremities and significant vulvar edema. Her blood pressure was normal and deep tendon reflexes were brisk. Labs showed elevated liver enzymes (AST 137 U/L and ALT 96 U/L) but no proteinuria. A diagnosis of Mirror Syndrome was made on the basis of moderate maternal edema and fetal hydrops. Repeat ultrasound showed progression of the fetal hydrops with worsening of the anemia in the ex-donor twin (MCA PSV 1.77 MoM) without change in the exrecipient (MCA-PSV 1.18 MoM), excluding twin anemia polycythemia sequence (TAPS) [3]. A decision was made for intrauterine blood transfusion of the ex-donor. After extensive counselling, the patient elected to proceed with intrauterine transfusion. At the time of procedure, an intraperitoneal approach was chosen due to limited sonographic imaging due to significant chorioamniotic separation which was likely related to the recent laser procedure and close location of both umbilical cords. Nine ml of donor red blood cells were transfused into the peritoneal cavity of the ex-donor twin. Detailed ultrasound evaluation the following day revealed resolution of hydrops and marked improvement in MCA-PSV (1.3 MoM). The fetal ascites completely resolved following intraperitoneal transfusion. Resolution of fetal hydrops was followed by gradual improvement of the maternal Mirror Syndrome with disappearance of maternal edema and decrease of the liver enzymes levels over 5 days. At 27 weeks and 1 day, the patient had preterm premature rupture of membranes, went into labor and delivered two live born male infants who had uncomplicated NICU admissions for prematurity. Both boys are doing well as of their 4 month followup visit. Mirror Syndrome (or Ballantyne Syndrome) is a rare condition in which the mother mimics the hydropic fetus by developing generalized edema. Beside edema, the syndrome is frequently associated with pre-eclampsia or hypertension, proteinuria, pulmonary edema, high perinatal mortality and maternal morbidity [4]. Although spontaneous resolution of Mirror Syndrome has been rarely reported with some cases of hydrops secondary to parvovirus infection [5] and fetal demise [6], most cases require immediate delivery to treat the condition and prevent serious maternal morbidity and mortality [7,8]. Interestingly in our case, the Mirror Syndrome resolved following intrauterine transfusion for fetal anemia and hydrops that followed laser ablation for treatment of TTTS. The ex-donor required only one intrauterine blood transfusion presumably because the disease process was stopped by laser ablation of the communicating anastomoses. This case report adds to the literature by providing additional evidence that Mirror Syndrome may be resolved by correcting the underlying insult, and that in the absence of unmanageable hypertension or other complication of preeclampsia, immediate delivery is not always necessary.