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O127 SCAR PREGNANCIES: EARLY DIAGNOSIS ALLOWS CONSERVATIVE NON SURGICAL MANAGEMENT
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
health for stabilizing patient before transfer to higher facility, they noted lack of knowledge to give the intervention, fear attitude recognizing the side effects of MgSO4, and lack of effort by midwife and the stakeholders to improve their skill competency to use the medicine as mentioned in the institutional guidelines. Care had barriers of limited drugs and availability of equipment and the efforts from health department to review the feasibility of the midwife practice were not been completely considered. The influence of social factors also contributed to the delay of management to transfer patient and the difficulty of midwife to make a clinical decision making. Conclusions: The case study highlights the complexities of barriers to optimize the utilization of MgSO4 in referral case from midwife in private practice to higher facilities. A better understanding of midwife clinical competency and standard obstetrics practice to facilitate management of preeeclampsia should be the main focus intervention by stakeholders to improve the midwife capacity in translation the evidence of clinical practice. O127 SCAR PREGNANCIES: EARLY DIAGNOSIS ALLOWS CONSERVATIVE NON SURGICAL MANAGEMENT L. Giambanco1 , T. Doveri1 , M.L. Amico1 , F. Forlani1 , D. Incandela1 , L. Alio1 , G. Cali’1 . 1 Obstetrics and Gynecology Department Civico Hospital, Palermo, Italy Objectives: Scar pregnancy is an ectopic pregnancy with a peculiar localization of placenta on/in previous hysterotomy site. Scar pregnancy could be cause of placenta accreta, uterine rupture, massive hemorrhage and so on. Early diagnosis of abnormal localization could preserve the woman from dangerous and life-threatening complications and her fertility as well. Transvaginal sonography performed in first trimester can identify scar pregnancies. Materials: Between 2009 and 2011 we diagnosed 16 scar pregnancies by transvaginal and transabdominal sonography, all of these patients had at least 1 previous caesarean section. Methods: Diagnostic criteria we look for are (fig. 1): an intrauterine gestational sac with localization on the anterior uterine wall, at internal orifice, thinnening of myometrial layer, defect of decidua basalis between placenta and myometrium and abnormal placental vascularization. Our purpose was to identify as soon as possible scar pregnancies in order to reduce maternal morbidity and mortality.
Figure 1. Results: In 14 of these women we were able to identify the abnormal localization on gestational sac at 7–12 weeks. All of them underwent conservative treatment: local or systemic Metotrexate, echoguided curettage after uterine arteries embolization. In two patients we performed an emergency laparotomy because of acute and massive hemorrhage.
S305
Conclusions: Diagnostic accuracy of ultrasonography in seconda and third trimester of pregnancy is higher, but the timing of diagnosis is too late for preventing major complications. Early first trimester diagnosis enable a conservative management, as reported by Literature and our data. O128 ISOBARIC MYOMECTOMY: SURGICAL AND REPRODUCTIVE OUTCOMES OF 5 YEARS EXPERIENCE G. Cammareri1 , C. Lanzani1 , F. Cirillo1 , E.A. Macalli1 , A. Turri1 , S. Rehman1 , F. Buzzella1 , E.M. Ferrazzi1 . 1 Hsp Buzzi, Milano, Milano, Italy Objectives: To investigate the feasibility of isobaric myomectomy and the reproductive outcomes. Materials: We performed a retrospective analysis of 207 isobaric myomectomies, between October 2005 and December 2010Methods: We included all women with 1 or more uterine myomas measuring more than 4 cm, symptomatic or progressively enlarging that underwent isobaric myomectomy, using a subcutaneous lifting system and laparotomic instruments. For reproductive outcomes, we performed a telephonic follow up, including 109 women aged less than 43 years. Results: The number of myomas removed per patient was 2.2±1.9 and diameter of the biggest fibroid was 7.0±2.5 cm. The biggest fibroid was intramural in 76% and subserosal in 24% of cases. The median operating time was 95 [70–125] minutes with a correlation with total volume of myomas, maximum volume and number of myomas removed. The mean blood loss was 200 [100– 450] mL. No intra-operative local vasoconstrictive drugs were used. Ninety-seven interventions were performed under spinalepidural anesthesia (46.9%) and 110 under general anesthesia. The conversion rate to laparotomic procedure was 5.8%. Blood transfusion rate was 2%. Two major complications (1%) were observed after the procedure: two cases of haemoperitoneum respectively caused by bleeding from the major ancillary port and from the uterine suture and treated by laparotomic intervention. No conversions to hysterectomy were performed. For reproductive outcomes, we included 109 women: in this cohort, no conversions to laparotomy were required. Six months waiting period after surgery was suggested. After intervention, 33 women wished to conceive and 26 became pregnant. There were no significant differences in clinical and demographic characteristics between women who conceived and women who did not. Early miscarriage occurred in 4 cases. Eleven patients delivered by elective Caesarean Section. Eleven women underwent a trial of labour and 9 women delivered vaginally. No uterine rupture occurred. Conclusions: Isobaric gasless myomectomy is a safe and reliable procedure, it has good reproductive outcome and it is possible to be performed under spinal-epidural anaesthesia, both for large and multiple intramural or subserosal uterine myomas. In our survey, although with small numbers, we did not have any uterine rupture, even in trial of labour. This fact could confirm the strength and safety of the uterine suture of myomectomy performed during gasless interventions, using traditional laparotomic instruments O129 OFFICE HYSTEROSCOPIC MYOMECTOMY: EFFECTIVE AND EFFICIENT PROCEDURE G. Cammareri1 , A. Turri1 , C. Lanzani1 , S. Rehman1 , F. Cirillo1 , F. Buzzella1 , E.M. Ferrazzi1 , S. Di Francesco1 . 1 Ospedale Vittore Buzzi, Milano, Italy Objectives: Hysteroscopic myomectomy is the standard minimally invasive surgical procedure for treating submucous fibroids. Office hysteroscopic myomectomy is a safe and well tolerated procedure. Submucosal myomas G0 and G1 <15mm may be successfully treated in an outpatient setting. On the contrary, there is still no single technique proven to be equally superior for treating G2
health for stabilizing patient before transfer to higher facility, they noted lack of knowledge to give the intervention, fear attitude recognizing the side effects of MgSO4, and lack of effort by midwife and the stakeholders to improve their skill competency to use the medicine as mentioned in the institutional guidelines. Care had barriers of limited drugs and availability of equipment and the efforts from health department to review the feasibility of the midwife practice were not been completely considered. The influence of social factors also contributed to the delay of management to transfer patient and the difficulty of midwife to make a clinical decision making. Conclusions: The case study highlights the complexities of barriers to optimize the utilization of MgSO4 in referral case from midwife in private practice to higher facilities. A better understanding of midwife clinical competency and standard obstetrics practice to facilitate management of preeeclampsia should be the main focus intervention by stakeholders to improve the midwife capacity in translation the evidence of clinical practice. O127 SCAR PREGNANCIES: EARLY DIAGNOSIS ALLOWS CONSERVATIVE NON SURGICAL MANAGEMENT L. Giambanco1 , T. Doveri1 , M.L. Amico1 , F. Forlani1 , D. Incandela1 , L. Alio1 , G. Cali’1 . 1 Obstetrics and Gynecology Department Civico Hospital, Palermo, Italy Objectives: Scar pregnancy is an ectopic pregnancy with a peculiar localization of placenta on/in previous hysterotomy site. Scar pregnancy could be cause of placenta accreta, uterine rupture, massive hemorrhage and so on. Early diagnosis of abnormal localization could preserve the woman from dangerous and life-threatening complications and her fertility as well. Transvaginal sonography performed in first trimester can identify scar pregnancies. Materials: Between 2009 and 2011 we diagnosed 16 scar pregnancies by transvaginal and transabdominal sonography, all of these patients had at least 1 previous caesarean section. Methods: Diagnostic criteria we look for are (fig. 1): an intrauterine gestational sac with localization on the anterior uterine wall, at internal orifice, thinnening of myometrial layer, defect of decidua basalis between placenta and myometrium and abnormal placental vascularization. Our purpose was to identify as soon as possible scar pregnancies in order to reduce maternal morbidity and mortality.
Figure 1. Results: In 14 of these women we were able to identify the abnormal localization on gestational sac at 7–12 weeks. All of them underwent conservative treatment: local or systemic Metotrexate, echoguided curettage after uterine arteries embolization. In two patients we performed an emergency laparotomy because of acute and massive hemorrhage.
S305
Conclusions: Diagnostic accuracy of ultrasonography in seconda and third trimester of pregnancy is higher, but the timing of diagnosis is too late for preventing major complications. Early first trimester diagnosis enable a conservative management, as reported by Literature and our data. O128 ISOBARIC MYOMECTOMY: SURGICAL AND REPRODUCTIVE OUTCOMES OF 5 YEARS EXPERIENCE G. Cammareri1 , C. Lanzani1 , F. Cirillo1 , E.A. Macalli1 , A. Turri1 , S. Rehman1 , F. Buzzella1 , E.M. Ferrazzi1 . 1 Hsp Buzzi, Milano, Milano, Italy Objectives: To investigate the feasibility of isobaric myomectomy and the reproductive outcomes. Materials: We performed a retrospective analysis of 207 isobaric myomectomies, between October 2005 and December 2010Methods: We included all women with 1 or more uterine myomas measuring more than 4 cm, symptomatic or progressively enlarging that underwent isobaric myomectomy, using a subcutaneous lifting system and laparotomic instruments. For reproductive outcomes, we performed a telephonic follow up, including 109 women aged less than 43 years. Results: The number of myomas removed per patient was 2.2±1.9 and diameter of the biggest fibroid was 7.0±2.5 cm. The biggest fibroid was intramural in 76% and subserosal in 24% of cases. The median operating time was 95 [70–125] minutes with a correlation with total volume of myomas, maximum volume and number of myomas removed. The mean blood loss was 200 [100– 450] mL. No intra-operative local vasoconstrictive drugs were used. Ninety-seven interventions were performed under spinalepidural anesthesia (46.9%) and 110 under general anesthesia. The conversion rate to laparotomic procedure was 5.8%. Blood transfusion rate was 2%. Two major complications (1%) were observed after the procedure: two cases of haemoperitoneum respectively caused by bleeding from the major ancillary port and from the uterine suture and treated by laparotomic intervention. No conversions to hysterectomy were performed. For reproductive outcomes, we included 109 women: in this cohort, no conversions to laparotomy were required. Six months waiting period after surgery was suggested. After intervention, 33 women wished to conceive and 26 became pregnant. There were no significant differences in clinical and demographic characteristics between women who conceived and women who did not. Early miscarriage occurred in 4 cases. Eleven patients delivered by elective Caesarean Section. Eleven women underwent a trial of labour and 9 women delivered vaginally. No uterine rupture occurred. Conclusions: Isobaric gasless myomectomy is a safe and reliable procedure, it has good reproductive outcome and it is possible to be performed under spinal-epidural anaesthesia, both for large and multiple intramural or subserosal uterine myomas. In our survey, although with small numbers, we did not have any uterine rupture, even in trial of labour. This fact could confirm the strength and safety of the uterine suture of myomectomy performed during gasless interventions, using traditional laparotomic instruments O129 OFFICE HYSTEROSCOPIC MYOMECTOMY: EFFECTIVE AND EFFICIENT PROCEDURE G. Cammareri1 , A. Turri1 , C. Lanzani1 , S. Rehman1 , F. Cirillo1 , F. Buzzella1 , E.M. Ferrazzi1 , S. Di Francesco1 . 1 Ospedale Vittore Buzzi, Milano, Italy Objectives: Hysteroscopic myomectomy is the standard minimally invasive surgical procedure for treating submucous fibroids. Office hysteroscopic myomectomy is a safe and well tolerated procedure. Submucosal myomas G0 and G1 <15mm may be successfully treated in an outpatient setting. On the contrary, there is still no single technique proven to be equally superior for treating G2