Faculty Bibliography

BACKGROUND: Cesarean scar pregnancy and cervical pregnancy are unrelated forms of pathological pregnancies carrying significant diagnostic and treatment challenges, with a wide range of treatment effectiveness and complication rates ranging from 10 to 62%. At times, lifesaving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single balloon catheter for treatment of cesarean scar pregnancy after local injection of methotrexate we evaluated the use of a double balloon catheter to terminate the pregnancy while preventing bleeding without any additive treatment. This is a retrospective study. OBJECTIVES: To describe the placement of a cervical ripening double balloon catheter as a novel minimally invasive treatment in patients with cesarean scar and cervical pregnancies to terminate the pregnancy and at the same time prevent bleeding by compressing the blood supply of the gestational sac. MATERIAL AND METHODS: Patients with diagnosed, live cervical pregnancy and cesarean scar pregnancy between 6 and 8 weeks' gestation were considered for the office based treatment. Paracervical block with 1% lidocaine was administered in 3 patients for pain control. Insertion of the catheter and inflation of the upper balloon were done under transabdominal ultrasound guidance. The lower (pressure) balloon was inflated opposite the gestational sac under transvaginal ultrasound guidance. After an hour, the area of the sac was scanned. When fetal cardiac activity was absent and no bleeding was noted, patients were discharged. After 2-3 days a follow-up appointment was scheduled for possible catheter removal. Serial ultrasound (US) and serum hCG were followed weekly or as needed. RESULTS: Three live cervical pregnancies and 7 live cesarean scar pregnancies were successfully treated. Median gestational age at treatment was 6 6/7 weeks (range 6 1/7 - 7 4/7 weeks). Patients' acceptance for the double balloon treatment was high in spite of the initial low abdominal pressure felt at the inflation of the balloons. All but one patient noted vaginal spotting at the follow-up appointment. Only one patient experienced bleeding of dark blood. The balloons were in place for a median of 3 days (range 1- 5 days). Median time from treatment to total drop of hCG was 49 days (range 28 - 97 days). CONCLUSION: The double balloon is a successful, minimally invasive and well tolerated single treatment for cervical pregnancy and cesarean scar pregnancy.. This simple treatment method has four main advantages: It effectively stops embryonic cardiac activity, prevents bleeding complications, does not require any additional invasive therapies and is familiar to obstetricians/gynecologists who use the same cervical ripening catheters for labor induction. Its wider application, however, has to be validated on a larger patient population.

BACKGROUND: Mechanical alteration of the cervical angle has been proposed to reduce spontaneous preterm birth (sPTB). Performance of the uterocervical angle (UCA) as measured by ultrasound for predicting sPTB is poorly understood. OBJECTIVE: To determine whether a novel ultrasonographic marker, UCA, correlates with risk of sPTB in a general population. STUDY DESIGN: We conducted a retrospective cohort study from May 2014 to May 2015 of singleton gestations between 16 0/7 - 23 6/7 weeks undergoing transvaginal ultrasound (TVU) for cervical length (CL) screening. Images were re-measured for UCA between the lower uterine segment and the cervical canal. Primary outcome was prediction of sPTB <34 weeks and <37 weeks by UCA and secondary outcome evaluated CL and sPTB. RESULTS: A total of 972 women were studied. The rate of sPTB in this cohort was 9.6% for delivery <37 weeks and 4.5% for <34 weeks. A UCA of >/=95o was significantly associated with sPTB <37 weeks with sensitivity of 80% (p<0.001, CI 0.70-0.81, NPV 95%). A UCA of >/=105 o predicted sPTB <34 weeks with sensitivity of 81% (p<0.001, CI 0.72-0.86, NPV 99%). CL /=95o and >/=105o detected during the 2nd trimester was associated with an increased risk for sPTB <37 and <34 weeks, respectively. UCA performed better than CL in this cohort. Our data indicate that UCA is a useful, novel transvaginal ultrasonographic marker that may be used as a screening tool for sPTB.

BACKGROUND: Ruptured ectopic pregnancy accounts for more cases of spontaneous hemoperitoneum than does the less frequently described acute bleeding from pedunculated uterine leiomyomata. When the latter does occur, management has consisted of laparotomy and either hemostatic suture or cauterization, myomectomy, or hysterectomy. CASE: We report a case of hemoperitoneum secondary to active bleeding from a pedunculated uterine fibroid notable for the presence of a concomitant tubal abortion as well as for the minimally invasive, fertility-sparing management approach. The patient underwent an uncomplicated laparoscopic myomectomy and was discharged home on the first postoperative day. CONCLUSION: Laparoscopic myomectomy is a safe, feasible alternative in the management of hemoperitoneum from pedunculated leiomyomata.