No abstract

OBJECTIVE: Uterine leiomyomas are the most frequent benign gynecologic pelvic tumors in women, which originate from smooth muscle cells of the uterus. Intra-operative bleeding and the increased need for blood transfusion and iron therapy are major challenges with abdominal myomectomy. Our objective is to compare the effectiveness of preoperative sublingual misoprostol 200 vs. 400 mcg for reducing blood loss during and after abdominal myomectomy.DESIGN: A randomized, double-blind, clinical trial (ClinicalTrials.gov: NCT02709564).MATERIALS AND METHODS: Patients with documented uterine fibroids on pelvic imaging and scheduled for abdominal myomectomy were invited to participate in our study. We included women aged (18-50 years) with five or less symptomatic subserous or intramural fibroids, Preoperative hemoglobin level is >8 g/dl, and uterine size is less than 24 weeks gestation. The eligible women were randomized (1:1) to either (group A) received two tablets of sublingual misoprostol 400 mcg at 3 hours and 1 hour before the surgery and (group B) received one tablet of sublingual misoprostol 200 mcg and one placebo tablet at the previously mentioned schedule. The primary outcome was the difference in the mean amount of intraoperative blood loss during myomectomy. The secondary outcomes included the change of hemoglobin (HB) before and 24 hours after surgery, duration of surgery, postoperative blood transfusion and the side effects of the drug. Mann Whitney test and Fisher's exact test were used for the analysis of the outcomes.RESULTS: Eighty women were enrolled and randomized (n¼40 in each arm). No difference between both groups regarding age, parity, BMI, type, number, size of fibroids and the total uterine size. Estimated blood loss was significantly lower in the misoprostol 400 mcg group (373.3AE55.6 vs. 560.0AE105.2 ml, p<0.001). Moreover, the reduction in HB level was significantly lower in the misoprostol 400 mcg group (0.8AE0.18 vs. 1.7AE0.38 g/dL, p<0.001). The operative duration was significantly shorter in the misoprostol 400 mcg group (91.3AE5.7 vs. 111.2AE6.3 minutes, p<0.001). Seven cases required a blood transfusion in the misoprostol 200 mcg group versus two cases in the other group (p¼0.03). No difference between both groups reading the side effects of misoprostol.CONCLUSIONS: Sublingual misoprostol 400 mcg is an effective and safe method for reduction of blood loss and need for blood transfusion during abdominal myomectomy.SUPPORT: None.

No abstract

Background Pneumopericardium is an uncommon clinical finding. It most commonly occurs after chest trauma but can also emerge as a complication following interventional or surgical procedures and can result in life-threatening complications. A high index of clinical suspicion should be present and once the condition is recognized, it should be managed promptly. Paucity of literature on pneumopericardium makes outlining any new case of paramount importance to emphasize the aspects of diagnosis and management of this rare condition. Case summary A 59-year-old woman with severe mitral valve and moderate tricuspid valve regurgitation underwent mitral and tricuspid valve repair with uneventful post-operative in-hospital stay. She presented 10 days after discharge with progressive shortness of breath. Chest X-ray revealed right hydropneumothorax. Transthoracic echocardiography (TTE) performed in the emergency department showed an apparently small pericardial effusion with patient in supine position; the effusion size increased substantially when imaging in left lateral decubitus, with presence of intrapericardial air bubbles. Computed tomography scan of the chest confirmed the presence of right hydropneumothorax and hydropneumopericardium, with a communicating pleuro-pericardial tract. The patient underwent chest tube placement which successfully decompressed both pleural and pericardial space. Discussion Hydropneumopericardium is a rare post-operative complication. Comprehensive TTE with imaging from multiple acoustic windows is mandatory when evaluating the extent of pericardial effusion. Presence of cardiac tamponade is crucial in determining the management plan.

OBJECTIVE: In 1992, HR 4773, the Fertility Clinic Success Rate and Certification Act, also known as the Wyden bill, was passed mandating public reporting of fertility clinic pregnancy success rates. Currently, >90% of ART clinics in the USA report to SART. The CDC, SART and ASRM work together to publish annual reports of clinic's pregnancy outcomes. SART warns that ''Accurate and complete reporting of ART success rates is complicated. Clinics may have differences in patient selection, treatment approaches, and cycle reporting practices which may inflate or lower pregnancy rates relative to another clinic. This report is best understood in consult with your physician.'' Furthermore, ''success rates should not be used to compare treatment centers.'' In spite of this, patients rely on this information to decide which center they will ultimately choose for their fertility treatment. The objective of this study was to compare the ranking of live birth rate (LBR), singleton live birth rate (SLBR), and weighted 'risk score' ranking based on risk factors for morbidity/mortality associated with multiple gestation in clinics reporting R 1000 total cycles annually.DESIGN: Cross-sectional evaluation. MATERIALS AND METHODS: The 2017 SART Preliminary Data report was reviewed for all reporting ART clinics. Those clinics reporting R 1,000 total cycles annually were included in our analysis, for a total of 62 clinics. LBR, SLBR, twin and triplet rates were recorded for each of the clinics. A weighted 'risk score' was then calculated for each clinic in the following manner: twin rate x 8 + triplet rate x 21. The weighted 'risk score' assigned to twin and triplet gestations was derived from published relative risk data of prematurity and low birth weight of twin and triplet gestations compared to singletons, as these have been shown to be the principal risk factors for morbidity/mortality in multiple gestation pregnancies. All clinics were subsequently ranked into quartiles with regards to LBR and 'risk score'.RESULTS: Of the 15 clinics in the top quartile with respect to LBR, only one clinic also ranked in the lowest quartile of 'risk score'. Of the remaining 14 clinics, 5 ranked in the highest 'risk score' quartile and 5 in the second highest 'risk score' quartile. Therefore, <30% of the clinics ranking in the highest quartile for LBR also ranked in the top two quartiles for safety.CONCLUSIONS: Our study showed that out of the 62 highest volume ART clinics reporting to SART, two thirds of those in the top quartile for LBR are in the bottom two quartiles with respect to weighted 'risk score', with one third ranking in the highest 'risk core' quartile. Only one clinic was in the top quartile in both fields. This is a manifestation of the incentive to achieve a higher LBR, commonly acknowledged to be the most referenced statistic reported by SART, at the cost of a higher risk of multiple gestation.Though not intended to be a tool for clinic comparison and ranking, SART is clearly used in this manner. We argue that more attention sho...