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Ilan E Timortritsch - One of the best experts on this subject based on the ideXlab platform.
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a new minimally invasive treatment for cesarean scar Pregnancy and Cervical Pregnancy
Obstetrical & Gynecological Survey, 2017Co-Authors: Ilan E Timortritsch, Ana Monteagudo, Terriann Bennett, Christine Foley, Joanne Ramos, Andrea Kaelin AgtenAbstract: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, life-saving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single-balloon catheter for the 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 was a retrospective study. Objectives The objective of the study was 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. Study Design 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 human chorionic gonadotropin 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 through 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 1 patient noted vaginal spotting at the follow-up appointment. Only 1 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 the total drop of human chorionic gonadotropin 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 4 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.
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foley balloon catheter to prevent or manage bleeding during treatment for Cervical and cesarean scar Pregnancy
Ultrasound in Obstetrics & Gynecology, 2015Co-Authors: Ilan E Timortritsch, G Cali, Ana Monteagudo, Nizar Khatib, R E Berg, F Forlani, E AvizovaAbstract:Objective To demonstrate the efficacy of placement and inflation of Foley balloon catheters prophylactically to prevent, or as an adjuvant therapy to control, bleeding in women undergoing treatment for Cesarean scar Pregnancy (CSP) or Cervical Pregnancy (CxP). Methods This was a retrospective study of 18 women with either CSP (n = 16) or CxP (n = 2), who underwent Foley balloon catheter placement under continuous transvaginal or transabdominal ultrasound guidance to prevent or manage bleeding following treatment, which in most cases comprised local (intragestational sac) and intramuscular (IM) methotrexate (MTX) injections. In eight cases, the balloon catheter was placed immediately following local and/or IM MTX treatment, either because of bleeding or prophylactically; in eight cases, the catheter was placed as part of a two-step protocol, with patients first treated with local and IM MTX injection, then suction aspiration on Day 4 or 5, followed by planned insertion of a balloon catheter; in one patient the balloon was placed on Day 21 after local and IM MTX treatment, due to sudden bleeding; and in one case of a heterotopic Pregnancy, one intrauterine and one Cervical, the balloon was placed due to severe bleeding. Human chorionic gonadotropin (hCG) levels were evaluated weekly following MTX injection. Results Gestational ages at balloon placement ranged between 5 and 12 + 2 weeks. All embryos/fetuses, with the exception of the Cervical heterotopic one, had heart activity and catheter placement was well-tolerated by all women. The balloon tamponade effectively reduced or prevented maternal vaginal bleeding in all except one patient; this woman had a heterotopic CxP and required abdominal robotic cerclage to control the bleeding. Catheters were kept in place for a mean of 3.6 (range, 1–6) days. hCG levels returned to low or zero levels within 19–82 days following MTX injection. Fifteen women required antibiotic treatment following the procedure. One woman with CSP developed an arteriovenous malformation requiring uterine artery embolization. Conclusion Ultrasound-guided placement and inflation of Foley balloon catheters was easy to perform and well-tolerated by patients undergoing treatment for CSP or CxP, and successfully prevented or helped in the management of bleeding complications. Based on our experience and previous publications we suggest having the option of balloon catheter insertion available when local treatment of CSP or CxP is undertaken. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.
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successful management of viable Cervical Pregnancy by local injection of methotrexate guided by transvaginal ultrasonography
American Journal of Obstetrics and Gynecology, 1994Co-Authors: Ilan E Timortritsch, Ana Monteagudo, Edgar O Mandeville, David B Peisner, Guido Parra Anaya, Exenia PirroneAbstract:We evaluated the feasibility of transvaginal methotrexate injection of viable Cervical pregnancies to avoid complications of the "classic" surgical procedures in use and to preserve future fertility. Five viable Cervical pregnancies, at 6 to 8 weeks, were treated. In three patients a spring-loaded automated puncture device and in two a manually operated simple needle guide mated to and guided by a transvaginal ultrasonography probe were used with 21-gauge needles. The puncture and injection treatment was successful and without complications in all five cases presented. This procedure may become a useful alternative to other, more radical or complex surgical approaches.
Mahmood K Razavi - One of the best experts on this subject based on the ideXlab platform.
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pelvic arterial embolization for control of obstetric hemorrhage a five year experience
American Journal of Obstetrics and Gynecology, 1999Co-Authors: Ernst Hansch, Usha Chitkara, Jessica Mcalpine, Yasser Y Elsayed, Michael D Dake, Mahmood K RazaviAbstract:OBJECTIVE: Obstetric hemorrhage is a significant cause of maternal morbidity and death. Postpartum hemorrhage that cannot be controlled by local measures has traditionally been managed by bilateral uterine artery or hypogastric artery ligation. These techniques have a high failure rate, often resulting in hysterectomy. In contrast, endovascular embolization techniques have a success rate of >90%. An additional benefit of the latter procedure is that fertility is maintained. We report our experience at Stanford University Medical Center in which this technique was used in 6 cases within the past 5 years. STUDY DESIGN: Six women between the ages of 18 and 41 years underwent placement of arterial catheters for emergency (n = 3) or prophylactic (n = 3) control of postpartum bleeding. Specific diagnoses included Cervical Pregnancy (n = 1), uterine atony (n = 3), and placenta previa and accreta (n = 2). RESULTS: Control of severe or anticipated postpartum hemorrhage was obtained with transcatheter embolization in 4 patients. A fifth patient had balloon occlusion of the uterine artery performed prophylactically, but embolization was not necessary. In a sixth case, bleeding could not be controlled in time, and hysterectomy was performed. The only complication observed with this technique was postpartum fever in 1 patient, which was treated with antibiotics and resolved within 7 days. CONCLUSIONS: Uterine artery embolization is a superior first-line alternative to surgery for control of obstetric hemorrhage. Use of transcatheter occlusion balloons before embolization allows timely control of bleeding and permits complete embolization of the uterine arteries and hemostasis. Given the improved ultrasonography techniques, diagnosis of some potential high-risk conditions for postpartum hemorrhage, such as placenta previa or accreta, can be made prenatally. The patient can then be prepared with prophylactic placement of arterial catheters, and rapid occlusion of these vessels can be achieved if necessary.
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pelvic arterial embolization for control of obstetric hemorrhage a five year experience
American Journal of Obstetrics and Gynecology, 1999Co-Authors: Ernst Hansch, Usha Chitkara, Jessica Mcalpine, Yasser Y Elsayed, Michael D Dake, Mahmood K RazaviAbstract:Abstract Objective: Obstetric hemorrhage is a significant cause of maternal morbidity and death. Postpartum hemorrhage that cannot be controlled by local measures has traditionally been managed by bilateral uterine artery or hypogastric artery ligation. These techniques have a high failure rate, often resulting in hysterectomy. In contrast, endovascular embolization techniques have a success rate of >90%. An additional benefit of the latter procedure is that fertility is maintained. We report our experience at Stanford University Medical Center in which this technique was used in 6 cases within the past 5 years. Study Design: Six women between the ages of 18 and 41 years underwent placement of arterial catheters for emergency (n = 3) or prophylactic (n = 3) control of postpartum bleeding. Specific diagnoses included Cervical Pregnancy (n = 1), uterine atony (n = 3), and placenta previa and accreta (n = 2). Results: Control of severe or anticipated postpartum hemorrhage was obtained with transcatheter embolization in 4 patients. A fifth patient had balloon occlusion of the uterine artery performed prophylactically, but embolization was not necessary. In a sixth case, bleeding could not be controlled in time, and hysterectomy was performed. The only complication observed with this technique was postpartum fever in 1 patient, which was treated with antibiotics and resolved within 7 days. Conclusions: Uterine artery embolization is a superior first-line alternative to surgery for control of obstetric hemorrhage. Use of transcatheter occlusion balloons before embolization allows timely control of bleeding and permits complete embolization of the uterine arteries and hemostasis. Given the improved ultrasonography techniques, diagnosis of some potential high-risk conditions for postpartum hemorrhage, such as placenta previa or accreta, can be made prenatally. The patient can then be prepared with prophylactic placement of arterial catheters, and rapid occlusion of these vessels can be achieved if necessary. (Am J Obstet Gynecol 1999;180:1454-60.)
Jenta Shen - One of the best experts on this subject based on the ideXlab platform.
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transvaginal ultrasound guided treatment of Cervical Pregnancy
Obstetrics & Gynecology, 2007Co-Authors: Cherngjye Jeng, Jenta ShenAbstract:The objective was to describe our experience with sonographically guided injection of methotrexate and potassium chloride (KCl) to treat early Cervical Pregnancy. We prospectively reviewed all cases of Cervical pregnancies treated conservatively through transvaginal ultrasound-guided therapy at our institutions. Thirty-eight cases were identified from 1993 through 2004. All cases were managed with transvaginal intraamniotic and intrachorionic injection of 50 mg of methotrexate under ultrasound guidance. An additional intracardiac fetal injection of 2 mL KCl was given for those Cervical pregnancies with documented cardiac activity. Follow-up sonographic examinations and serum s-hCG measurements were performed twice weekly for 2 weeks after the procedure then weekly. The mean initial s-hCG level was 38948 milli-International Units/mL and ranged from 5608 to 103256 milli-International Units/mL for 22 cases with fetal heart activity and from 2765 to 18648 milli-International Units/mL for 16 cases without. Gestational age ranged from 5.4 to 14 weeks (mean 8.8 weeks). All Cervical pregnancies were successfully aborted with an average resolution of the Cervical mass in 49 days. Postoperative s-hCG declined to less than 5 milli-International Units/mL within a mean of 38 days. A mean 4.5-year follow-up showed that of 21 patients who desired Pregnancy 18 had achieved subsequent successful pregnancies. Cervical pregnancies can be successfully managed without surgical intervention through local injection of methotrexate and KCl. This treatment not only ablates the ectopic Pregnancy but also preserves the uterus for subsequent pregnancies. (authors)
Ana Monteagudo - One of the best experts on this subject based on the ideXlab platform.
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a new minimally invasive treatment for cesarean scar Pregnancy and Cervical Pregnancy
Obstetrical & Gynecological Survey, 2017Co-Authors: Ilan E Timortritsch, Ana Monteagudo, Terriann Bennett, Christine Foley, Joanne Ramos, Andrea Kaelin AgtenAbstract: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, life-saving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single-balloon catheter for the 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 was a retrospective study. Objectives The objective of the study was 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. Study Design 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 human chorionic gonadotropin 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 through 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 1 patient noted vaginal spotting at the follow-up appointment. Only 1 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 the total drop of human chorionic gonadotropin 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 4 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.
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foley balloon catheter to prevent or manage bleeding during treatment for Cervical and cesarean scar Pregnancy
Ultrasound in Obstetrics & Gynecology, 2015Co-Authors: Ilan E Timortritsch, G Cali, Ana Monteagudo, Nizar Khatib, R E Berg, F Forlani, E AvizovaAbstract:Objective To demonstrate the efficacy of placement and inflation of Foley balloon catheters prophylactically to prevent, or as an adjuvant therapy to control, bleeding in women undergoing treatment for Cesarean scar Pregnancy (CSP) or Cervical Pregnancy (CxP). Methods This was a retrospective study of 18 women with either CSP (n = 16) or CxP (n = 2), who underwent Foley balloon catheter placement under continuous transvaginal or transabdominal ultrasound guidance to prevent or manage bleeding following treatment, which in most cases comprised local (intragestational sac) and intramuscular (IM) methotrexate (MTX) injections. In eight cases, the balloon catheter was placed immediately following local and/or IM MTX treatment, either because of bleeding or prophylactically; in eight cases, the catheter was placed as part of a two-step protocol, with patients first treated with local and IM MTX injection, then suction aspiration on Day 4 or 5, followed by planned insertion of a balloon catheter; in one patient the balloon was placed on Day 21 after local and IM MTX treatment, due to sudden bleeding; and in one case of a heterotopic Pregnancy, one intrauterine and one Cervical, the balloon was placed due to severe bleeding. Human chorionic gonadotropin (hCG) levels were evaluated weekly following MTX injection. Results Gestational ages at balloon placement ranged between 5 and 12 + 2 weeks. All embryos/fetuses, with the exception of the Cervical heterotopic one, had heart activity and catheter placement was well-tolerated by all women. The balloon tamponade effectively reduced or prevented maternal vaginal bleeding in all except one patient; this woman had a heterotopic CxP and required abdominal robotic cerclage to control the bleeding. Catheters were kept in place for a mean of 3.6 (range, 1–6) days. hCG levels returned to low or zero levels within 19–82 days following MTX injection. Fifteen women required antibiotic treatment following the procedure. One woman with CSP developed an arteriovenous malformation requiring uterine artery embolization. Conclusion Ultrasound-guided placement and inflation of Foley balloon catheters was easy to perform and well-tolerated by patients undergoing treatment for CSP or CxP, and successfully prevented or helped in the management of bleeding complications. Based on our experience and previous publications we suggest having the option of balloon catheter insertion available when local treatment of CSP or CxP is undertaken. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.
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successful management of viable Cervical Pregnancy by local injection of methotrexate guided by transvaginal ultrasonography
American Journal of Obstetrics and Gynecology, 1994Co-Authors: Ilan E Timortritsch, Ana Monteagudo, Edgar O Mandeville, David B Peisner, Guido Parra Anaya, Exenia PirroneAbstract:We evaluated the feasibility of transvaginal methotrexate injection of viable Cervical pregnancies to avoid complications of the "classic" surgical procedures in use and to preserve future fertility. Five viable Cervical pregnancies, at 6 to 8 weeks, were treated. In three patients a spring-loaded automated puncture device and in two a manually operated simple needle guide mated to and guided by a transvaginal ultrasonography probe were used with 21-gauge needles. The puncture and injection treatment was successful and without complications in all five cases presented. This procedure may become a useful alternative to other, more radical or complex surgical approaches.
Exenia Pirrone - One of the best experts on this subject based on the ideXlab platform.
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successful management of viable Cervical Pregnancy by local injection of methotrexate guided by transvaginal ultrasonography
American Journal of Obstetrics and Gynecology, 1994Co-Authors: Ilan E Timortritsch, Ana Monteagudo, Edgar O Mandeville, David B Peisner, Guido Parra Anaya, Exenia PirroneAbstract:We evaluated the feasibility of transvaginal methotrexate injection of viable Cervical pregnancies to avoid complications of the "classic" surgical procedures in use and to preserve future fertility. Five viable Cervical pregnancies, at 6 to 8 weeks, were treated. In three patients a spring-loaded automated puncture device and in two a manually operated simple needle guide mated to and guided by a transvaginal ultrasonography probe were used with 21-gauge needles. The puncture and injection treatment was successful and without complications in all five cases presented. This procedure may become a useful alternative to other, more radical or complex surgical approaches.