OBJECTIVES:Retained products of conception (RPOC) occur in approximately 1% of term deliveries and may result in bleeding, infection, and reproductive complications. However, early postpartum symptoms and ultrasound findings are often nonspecific, making diagnosis challenging. This study evaluated whether transvaginal sonography performed 6 weeks postpartum can effectively stratify RPOC risk in suspected cases and guide follow-up and management. METHODS:In this prospective study, 116 hemodynamically stable women with risk factors for RPOC and without significant symptoms underwent transvaginal ultrasound 6 weeks postpartum. Findings were classified as high, moderate, or low probability based on the presence of an intrauterine mass, endometrial thickness, and vascularity. Low probability cases required no further evaluation, whereas those in the moderate and high probability groups were referred for diagnostic or operative hysteroscopy, respectively. RESULTS:Patients were categorized into high (19%), moderate (28%), and low (53%) probability groups. The prevalence of histologically confirmed RPOC in these groups was 50, 12.5, and 0%, respectively. Compared with prior studies that performed earlier postpartum assessments, evaluation at 6 weeks improved diagnostic accuracy, particularly in moderate probability cases, while predictive values in high and low probability groups remained comparable. CONCLUSIONS:Sonographic assessment at 6 weeks postpartum provides reliable risk stratification for RPOC and supports a more conservative management approach in hemodynamically stable women without significant symptoms by deferring imaging and potential interventions until completion of the postpartum period. This approach improves diagnostic accuracy in the moderate probability group while reducing false positives and unnecessary interventions.

Despite diagnostic advancements, ovarian pregnancy remains rare and challenging to detect preoperatively. This study examines 5 decades of trends, clinical features, and surgical outcomes in a single tertiary care center. A retrospective review was conducted of 59 women with primary ovarian pregnancy treated between 1971 and 2025, categorized into four periods: 1971–1989 (n = 20), 1990–2001 (n = 19), 2002–2013 (n = 7), and 2014–2025 (n = 13). Long-term fertility outcomes were assessed using updated institutional medical records supplemented by telephone contact when patients were reachable. Among 317,015 deliveries, 4357 ectopic pregnancies (1.4

OBJECTIVE:To demonstrate the use of ultrasound-guided hysteroscopic technique for the successful surgical management of a missed abortion in a patient with uterus didelphys and complex cervical anatomy. SETTING:The case was managed in a tertiary referral center with a multidisciplinary team. PARTICIPANTS:A 36-year-old woman, gravida 4 para 3, with a known Müllerian anomaly and right renal agenesis, presented with a missed abortion at 9 weeks of gestation. Although the anomaly was previously suspected, the exact diagnosis-whether bicornuate uterus or didelphys uterus-remained unclear due to the presence of a single identifiable cervix. In this case, ultrasound identified the pregnancy within the right uterine horn. INTERVENTIONS:Under general anesthesia, a thorough speculum examination revealed a potential opening to the right uterine horn. Ultrasound-guided cervical dilation was attempted but proved unsuccessful due to the tortuous nature of the canal. Therefore, ultrasound-guided hysteroscopic approach was employed with a multidisciplinary team including gynecology, anesthesia, and sonography specialists. Surgical hysteroscopy facilitated precise navigation and evacuation of the gestational sac from the right uterine horn under ultrasound guidance. The procedure was completed without complications. Hysteroscopic and sonographic follow-up after 2 months demonstrated a normal endometrial lining and no retained products of conception. CONCLUSION:This case underscores the importance of adapting surgical strategies to complex anatomical variations in patients with Müllerian anomalies. Ultrasound-guided hysteroscopy offers a safe and effective solution when standard methods such as D&C fail due to obstructive cervical anatomy. Its direct visualization capabilities allow for precise intervention, minimize procedural risks, and improve patient outcomes. Incorporating advanced hysteroscopic techniques into clinical practice is essential for managing challenging uterine malformations. VIDEO ABSTRACT.

STUDY OBJECTIVE:To evaluate the surgical management of early pregnancy loss by vacuum aspiration vs operative hysteroscopy in terms of feasibility, safety, and postoperative intrauterine adhesions (IUA) and retained products of conception (RPOC). DESIGN:A nonblinded randomized-controlled trial. SETTING:A university-affiliated department of obstetrics and gynecology. PARTICIPANTS:Study participation was offered to women with early (<10 gestational weeks) pregnancy loss. INTERVENTIONS:All procedures were performed under general anesthesia. Vacuum aspiration was performed by means of a plastic vacuum curette. Operative hysteroscopy was carried out by means of a tissue removal device (TruClear Elite hysteroscope mini, from Medtronic). The presence of IUA and RPOC was evaluated on 6-week postoperative hysteroscopy. RESULTS:A total of 100 patients underwent either vacuum aspiration (n = 50) or operative hysteroscopy (n = 50). The mean gestational age was similar in both groups (8.7 ± 0.7 vs 8.8 ± 0.9 weeks, respectively, p = .6). The operating room time and the procedure time were significantly shorter in the vacuum aspiration group compared with the hysteroscopy group (27.5 ± 6.3 vs 36.3 ± 6.7 minutes and 7.2 ± 2.5 vs 9.8 ± 3.7 minutes, respectively, p < .01). Two cases in the hysteroscopy group were converted to vacuum aspiration due to reduced visibility. The intraoperative complications included 2 cases of laryngospasm in the hysteroscopy group. Follow-up hysteroscopy was available for 90 patients. The rates of postoperative IUA were significantly higher in the vacuum aspiration group (19/42 cases, 45.2%) compared with the operative hysteroscopy group (2/48 cases, 4.2%) (p < .01). Suspected RPOC were diagnosed in 5/42 (11.9%) of the vacuum aspiration patients and 11/48 (22.9%) of the hysteroscopy patients (p = .1), however, pathology-confirmed RPOC were found in 3/42 (7.1%) and 6/48 (12.5%) cases, respectively (p = .4). CONCLUSION:Operative hysteroscopy for the surgical management of early pregnancy loss may safely reduce the rates of postoperative IUA compared to vacuum aspiration.

To quantify obstetric outcomes after prior myomectomy in a tertiary center and to explore whether operative and clinical characteristics are associated with uterine rupture. Single-center retrospective cohort of deliveries following laparotomic or laparoscopic myomectomy between August 2015 and January 2023. We extracted demographic, surgical, and obstetric data from electronic records, and analyzed only the first consecutive post-myomectomy pregnancy per patient. Sixty-three women delivered after prior myomectomy. 75.5

Background: Hysteroscopy without anaesthesia is a routine gynaecological procedure but is commonly associated with patient anxiety and pain. Objectives: To compare preoperative information provision using usual verbal interaction with the use of an animated video on patients’ anxiety and pain associated with outpatient hysteroscopy. Methods: Patients were allocated to receive verbal explanations immediately prior to the outpatient hysteroscopy or via an informative short, animated video. Main Outcome Measures: Proportion of patients with moderate-high preoperativee anxiety levels as assessed by the State-Trait Anxiety Inventory questionnaire. Secondary outcomes included maximal intraoperative pain levels recorded on a 10 cm visual analogue scale (VAS) completed directly after the procedure. Results: One hundred patients undergoing 78 diagnostic hysteroscopies and 22 operative hysteroscopies were included in the study, with 50 patients allocated to each intervention group. Preoperative moderate or high anxiety levels were reported by 28 participants who also had higher VAS pain scores (3.6±3.2 cm vs. 2.0±2.5 cm in the lower anxiety group, P=0.02). The rates of preoperative moderate/high anxiety levels were significantly higher in the standard verbal education group compared with the animated video group [19 (38.0%) vs. 9 (18.0%), respectively, P=0.04], although their VAS pain scores were not significantly different. The logistic regression analysis confirmed that a low level of anxiety was associated with education by an animated video (odds ratio: 2.9, 95% confidence interval: 1.1-7.6). Conclusions: Preoperative education by an animated video prior to hysteroscopy is associated with lower rates of moderate/high anxiety levels compared to the standard verbal education preparation. What is New? Animated videos are an effective and easy-to-implement tool that may reduce anxiety before office hysteroscopy.

The eccentric implantation of pregnancies in the upper lateral aspect of the uterine cavity is poorly defined clinically. The aim of the current study was to investigate whether differentiating between uterine anomalies that can lead to cavitary distortion has implications for the management of these pregnancies. Eight cases of first-trimester eccentric pregnancy implantation within the endometrial cavity (study group) were retrospectively identified. For each woman in the study group, 10 women identified as having a first-trimester concentric pregnancy implantation during the first-trimester US examination were retrieved from our database (control group). After delivery or pregnancy demise, the presence of uterine anomalies was assessed by a 3D-US examination in all patients. In the study group patients, an increased incidence of uterine anomalies (50.0

STUDY OBJECTIVE:To determine the association of repeat polypectomy with patient and/or polyp characteristics, surgical setting, and type of hysteroscopic equipment. METHODS:Retrospective cohort study including all women who had undergone operative hysteroscopy for the removal of endometrial polyps between 1/2012-12/2022 in our division. Operative hysteroscopy with resection of endometrial polyps was performed using a bipolar loop resectoscope, miniaturized hysteroscopic instruments (bipolar needle, scissors, and graspers), or a tissue-removal device (from April 2021), with or without general anesthesia. RESULTS:Benign polyps were removed in 722 women in an outpatient setting and without any anesthesia (n = 64, 8.9 %) or in an operating theatre under general anesthesia (n = 658, 91.1 %). Their mean age was 55.8 ± 12.4 years, 432 (59.8 %) were menopausal, and 41 (5.7 %) reported having previously undergone a polypectomy. The mean size of the resected polyp was 19.9 ± 8.0 mm, and ≥ 2 polyps were removed in 188 (26.0 %) cases. Repeat polypectomy was performed in 32 (4.4 %) women after 3.0 ± 1.9 years, and it was significantly more common among women whose index polypectomy was performed in an outpatient setting (12.5 % versus 3.6 % operating theatre, p = 0.005), and in women who underwent polypectomy by miniaturized hysteroscopic instruments compared with a loop resectoscope or a tissue removal device (8.3 %, 4.2 %, and 0 %, respectively, p = 0.03). On the multivariate analysis, hysteroscopy without anesthesia was significantly associated with repeat polypectomy (odds ratio = 3.5, 95 % confidence interval 1.1-12.1, p = 0.04), while the choice of hysteroscopic equipment was not (odds ratio = 1.1, 95 %, confidence interval 0.3-3.5, p = 0.9). Patient age, menopausal status, and size and number of polyps were not significantly associated with repeat polypectomy. CONCLUSIONS:Repeat hysteroscopic polypectomy is relatively uncommon and possibly associated with the choice of hysteroscopic equipment and provision of anesthesia.

STUDY OBJECTIVE:To investigate the feasibility of operative hysteroscopy by a hysteroscopic tissue removal system (HTRS) without anesthesia in women with endometrial polyps (EP) or retained products of conception (RPOC). DESIGN:Prospective observational cohort study. SETTING:University-affiliated Department of Obstetrics and Gynecology. PATIENTS:Consenting women aged >18 years diagnosed with EP or RPOC from 9/2022 to 8/2023 confirmed by a prior office hysteroscopy. INTERVENTIONS:Office-based vaginoscopic operative hysteroscopy without anesthesia using the Mini-Elite Truclear HTRS. Oral misoprostol was prescribed for cervical ripening. The patients rated intraoperative and 5-minute postoperative pain levels on a visual analog scale, with mild pain defined as a score of 0 to 4, moderate as 5 to 7, and severe as 8 to 10. A successful procedure was defined as complete removal of the pathology. MEASUREMENTS AND MAIN RESULTS:Fifty patients were included in this pilot study, and 47 (94.0%) procedures were completed successfully, including 21/24 (87.5%) cases of EP and all cases of RPOC (26/26, p = .06). No intra- or postoperative complications occurred. The intraoperative pain levels were rated as mild, moderate, and severe by 26 (52.0%), 16 (32.0%) and 8 (16.0%) patients, respectively. Severe intraoperative pain was more common in nulliparous women and those >10 years from their last vaginal delivery and was not associated with patient age, menopausal status, presence of abnormal uterine bleeding, or pathology size. Severe postoperative pain, reported by 5 (10.0%) patients, was significantly associated with removal of EP compared with RPOC, longer operative time, and nulliparity or >10 years from the last vaginal delivery. The procedure was considered acceptable by 46 (92.0%) patients, and 45 (90.0%) would recommend it to a friend/relative. CONCLUSIONS:Office-based operative hysteroscopy by the HTRS is successful and well tolerated by most women, especially for RPOC removal.

Study objective: Early diagnosis and treatment of endometriosis in adolescents and young women is considered essential for improving their quality of life and for prevention of long-term complications. In adult women with endometriosis, significant delays in diagnosis and medical or surgical treatment have been described. Our study aimed to investigate the delay in diagnosis and treatment of adolescents and young women with suspected endometriosis. Methods: A retrospective study of adolescents and young women (12-22 years-old) who were evaluated for suspected endometriosis at the endometriosis clinic in the Shamir medical center between January 2017 and December 2022. All patients were referred by their primary care gynecologists. The evaluation in the endometriosis clinic included targeted history, physical exam and a focused ultrasound survey for endometriosis (performed trans-abdominally in all cases, and trans-vaginally in sexually active women). Results: Out of 400 women with suspected endometriosis evaluated in our endometriosis clinic during the study period, 68 were adolescents and young women <22 years old. Their mean age at time of evaluation for endometriosis was 18 +/- 2.5 years, and the mean time-period from onset of symptoms to the endometriosis evaluation was 4.0 +/- 2.9 years. Their most common symptoms were dysmenorrhea (in 61 cases, 89.7 %), followed by gastrointestinal symptoms (in 32 cases, 47.1 %). In 30 (44.1 %) cases, hormonal treatment was prescribed by the primary care gynecologist prior to their appointment in the endometriosis clinic. On comparison of patients with delay of <4 years (N = 31) versus >= 4 years (N = 37) from symptom onset to the endometriosis evaluation, patients with shorter duration of symptoms were more likely to decline any hormonal treatment for endometriosis while patients with longer duration of symptoms were more likely to accept the recommendation for hormonal treatment (16.2 % versus 0 %, p = 0.02, and 83.8 % versus 100 %, p = 0.03, respectively). Conclusion: Adolescents and young women with suspected endometriosis may experience significant delays in diagnosis and medical care, similar to adult patients.

To describe the feasibility of hysteroscopy-assisted suction curettage for early pregnancy loss and to investigate whether it reduces the rates of retained products of conception (RPOC) and intrauterine adhesions (IUA). Prospective single-arm cohort study. University-affiliated Department of Obstetrics and Gynecology. Women admitted for surgical evacuation of early pregnancy loss were invited to participate in the study. Vaginal misoprostol was administered for cervical ripening preoperatively. Under general anesthesia, a diagnostic hysteroscopy was performed to identify the pregnancy’s implantation wall, followed by ultrasound-guided suction and curettage directed to the implantation wall, and then diagnostic hysteroscopy to verify complete uterine cavity emptying. Postoperative IUA were evaluated by follow-up office hysteroscopy. Identification of the pregnancy’s implantation wall on hysteroscopy, and intra-, and postoperative complications associated with the procedure. The evaluation of postoperative IUA was limited due to the COVID-19 pandemic-related restrictions on elective procedures. Forty patients were included in the study group. Their mean age was 34.0 ± 6.6 years, and their mean gestational age was 8.9 ± 1.6 weeks. The implantation wall was clearly visualized on hysteroscopy in 33 out of 40 cases (82.5

Purpose Women diagnosed with mid-trimester cervical insufficiency and dilatation are offered interventions to salvage and support the cervix, where the mainstay of therapy is emergency cervical cerclage. However, considering the significant morbidity associated with delivery in the extreme prematurity period, some women may opt for pregnancy termination. In addition, it is expected that elective cerclage in a subsequent pregnancy may yield better obstetrical results. The objective of this study was, therefore, to compare the obstetrical outcomes of emergency cerclage versus elective cerclage. Methods This is a retrospective cohort study of the pregnancy outcomes of women with a singleton pregnancy who underwent cervical cerclage at our institution between December 2008 and November 2021. Women who underwent emergency cervical cerclage due to painless dilatation in the second trimester were compared with women who underwent elective cerclage. Results Overall, 32 women who underwent emergency cerclage and 183 women who underwent elective cerclage were included. No cases of iatrogenic membrane rupture were noted during the cerclage procedure. There was no statistical difference between the emergency cerclage group and the elective cerclage group in the primary outcomes: gestational age at delivery (35.8 + 4.7 vs 36.3 + 4.9, p = 0.58, respectively), delivery in the extreme prematurity period (between 24 and 28 gestational weeks, 6.5% vs 2.3%, p = 0.21, respectively), and fetal or neonatal death (6.9% vs 6.3%, p = 0.91, respectively). Conclusion Although there are much less favourable circumstances, emergency cerclage is a safe procedure with comparable obstetrical outcomes to elective cerclage. Patient selection and experienced medical team may play a significant role in those cases.

STUDY OBJECTIVE:Recurrent torsion of otherwise normal adnexa (not involving adnexal cysts) has been reported in young girls and adolescents. Previous ovarian fixation techniques (oophoropexy), such as plication of the utero-ovarian ligament, appear to have limited efficacy in preventing recurrent torsion. A novel technique combining plication of the utero-ovarian ligament and suturing of the ovary to the round ligament has recently been described. In this study, we describe our short-term experience with the combined utero-ovarian and round ligament oophoropexy technique.METHODS:Patients who underwent combined oophoropexy as a primary fixation technique or as a secondary fixation technique (ie, after failure of a previous fixation) due to recurrent torsion of otherwise normal adnexa between January 2020 and December 2022 were included in this retrospective cohort study. Follow-up to assess for further torsion events was conducted by telephone interview.RESULTS:Ten patients underwent combined utero-ovarian and round ligament oophoropexy during the study period. In all cases, at least 2 episodes of torsion of otherwise normal adnexa were surgically diagnosed before oophoropexy (range 2-4). The median patient age at the time of combined oophoropexy was 21.8 years (range 9.1-35.7 years); 3 were premenarchal, and 7 were postmenarchal. After a median follow-up of 19.1 months (range 3.0-29.3 months), only 1 case of recurrent torsion occurred.CONCLUSION:Combined utero-ovarian and round ligament oophoropexy is novel oophoropexy procedure that may reduce the risk of recurrent torsion. However, longer follow-up is needed to determine its efficacy.

Normal and abnormal implantation of the gestational sac may affect obstetrical outcomes. We sought to evaluate whether ultrasound can correctly identify the first-trimester gestational sac implantation wall compared to diagnostic hysteroscopy.

This article presents an overview of the diagnosis and classification of retained products of conception (RPOC) as well as removal techniques and discusses the associated complications, advantages and disadvantages of these procedures. RPOC occur when tissue from the placenta or the fetus remain in the uterus after all types of termination of pregnancy and deliveries, including vaginal or cesarean delivery, spontaneous miscarriage, or induced medical or surgical abortion. The diagnosis is based on the combination of clinical findings and ultrasound (US) evaluation (gray-scale and Doppler flow). Hysteroscopy has emerged as the preferred treatment for women with RPOC largely due to its demonstrated safety, feasibility, low incidence of postoperative intrauterine adhesions (IUAs) and high rates of subsequent fertility. Furthermore, thanks to the availability of hysteroscopic tissue removal systems (HTRs) and the miniresectoscope, many hysteroscopic procedures can now be performed without anaesthesia or cervical dilation in an ambulatory setting. Further studies are required to provide a more comprehensive understanding of the reproductive outcomes in patients with pregnancies complicated by RPOC.

Purpose Recurrence of adnexal torsion involving otherwise normal adnexa is not rare. Various oophoropexy (ovarian fixation) procedures have been suggested to prevent recurrence, however, long-term information of their efficacy is lacking. The aim of this study was to investigate the recurrence rate of adnexal torsion following oophoropexy. Methods Retrospective cohort study, including all consecutive patients who underwent an oophoropexy procedure for the prevention of recurrent torsion of “normal adnexa” in our department from 2008 to 2021. Oophoropexy techniques included shortening of the utero-ovarian ligament (between 2008 to 2019) or combined utero-ovarian and round ligament fixation (from 2020). Results Twenty-one patients (age range 7-35 years) with a mean follow-up of 82.7 ± 60.6 months were identified. Fifteen of them (71.4%) were re-operated for recurrent torsion following an oophoropexy procedure, while six (28.6%) did not experience recurrence. Twelve (57.1%) torsion recurrences following an oophoropexy occurred within the first 2 postoperative years. There were no differences in mean age and menarchal status )pre- or post-menarchal) at the time of the first torsion event, age at the time of oophoropexy, oophoropexy side, number of adnexal torsion events before oophoropexy, and follow-up duration between those with and those without post-oophoropexy recurrences. Conclusion Oophoropexy procedures may not prevent recurrent torsion of otherwise normal adnexa. Further studies to determine whether combined fixation (utero-ovarian plication and round ligament) is more efficacious than isolated utero-ovarian plication for the prevention of recurrent torsion are warranted.