Publications by authors named "Ludovica Verrelli"

4 Publications

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Conservative cesarean scar pregnancy treatment: local methotrexate injection followed by hysteroscopic removal with hysteroscopic tissue removal system.

Fertil Steril 2021 Jul 18. Epub 2021 Jul 18.

Division of Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

Objective: To describe a conservative cesarean scar pregnancy (CSP) treatment in a patient with the desire for future pregnancy. To date, there is no gold standard for the management of a viable CSP. There is a wide range of treatment options that include major surgery and minimally invasive procedures. Moreover, after a minimally invasive treatment, the gestational sac may be visible at ultrasound for >6 months. The described technique may be useful to avoid complications related to the use of energy with a large reduction in operative times.

Design: Description of the technique with narrated video footage.

Setting: Academic tertiary hospital.

Patient(s): A 31-year-old woman with a previous cesarean section was referred to our clinic with lower abdominal pain. Transvaginal ultrasound revealed a gestational sac with a viable embryo located in the anterior isthmic region, suggestive of CSP at 9 weeks of gestation. Appropriate counseling describing the two diametrically opposite clinical management options was performed, and the patient decided to terminate the pregnancy. Informed consent was obtained from the patient.

Intervention(s): Hysteroscopy was performed under local anesthesia in an outpatient setting, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope (Karl Storz, Tuttlingen, Germany) with a 4.3-mm inner sheath and 5F instruments. A 3.7F needle (Deflux metal needle; Oceana Therapeutics, Edison, NJ) was pushed into the myometrial tissue surrounding the implantation site of the gestational sac at four different points. Six additional injections were performed into the gestational sac, and 50-mg methotrexate was injected. The appropriate follow-up was performed to determine the success of the procedure. β-Human chorionic gonadotropin was dosed weekly until negative. After 6 weeks, to remove the avascular trophoblastic remnants found at ultrasound evaluation, the patient underwent hysteroscopic removal with a 6-mm TruClear hysteroscopic tissue removal system (Medtronic Parkway, Minneapolis, MN). A contemporary transabdominal ultrasound was performed to minimize surgical risks.

Main Outcome Measure(s): Complete and conservative CSP treatment with the absence of surgical complications.

Result(s): Conservative cesarean scar pregnancy treatment was performed successfully with primary local methotrexate injection followed, after 6 weeks, by hysteroscopic removal of the CSP remnants with the TruClear hysteroscopic tissue removal system. The first procedure lasted 6 minutes, whereas hysteroscopic removal of the CSP lasted 5 minutes. Both procedures were performed in an outpatient setting, and no complications were detected during and after the treatments. The patient reported good health at the 1-month follow-up visit, and the ultrasound showed an empty isthmocele (Fig. 1).

Conclusion(s): Primary local methotrexate injection followed by hysteroscopic removal of the CSP remnants with the hysteroscopic tissue removal system may be a valuable treatment for women who desire pregnancy in the near future. This combined technique may avoid potential complications, such as thermal-induced myometrial injuries or uterine perforation. Moreover, the operator has the possibility to perform an under-vision procedure with a lower incidence of intraoperative and postoperative bleeding. Because it does not reduce fertility/pregnancy rate, this technique should be a valid option in patients who desire future pregnancy.
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http://dx.doi.org/10.1016/j.fertnstert.2021.06.034DOI Listing
July 2021

Erratum: Management of Endometriomas.

Semin Reprod Med 2017 07 16;35(4):390-392. Epub 2017 Oct 16.

Department of Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy.

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http://dx.doi.org/10.1055/s-0037-1606279DOI Listing
July 2017

White Leopard Skin Pattern at Hysteroscopy in a Case of Hematometra.

J Minim Invasive Gynecol 2018 02 19;25(2):324-325. Epub 2017 May 19.

Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy.

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http://dx.doi.org/10.1016/j.jmig.2017.05.007DOI Listing
February 2018

Management of Endometriomas.

Semin Reprod Med 2017 01 7;35(1):25-30. Epub 2016 Dec 7.

Department of Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy.

Ovarian endometriomas affect 17 to 44% of women with endometriosis, and are often associated with pelvic pain and infertility. Treatment options include expectant management, medical and/or surgical treatment, and in vitro fertilization and embryo transfer (IVF-ET). The choice of treatment depends mostly on the associated symptoms. In most cases, surgery is the preferred choice, since endometriomas do not respond to medical treatment, which may only treat associated pain. In case of infertility, IVF-ET may be a suitable alternative to surgery, particularly when there is no associated pain. According to the best available scientific evidence, laparoscopic excision of the endometrioma wall should be considered the procedure of choice. Concerns have been raised as to the possibility that surgical excision may damage the ovarian reserve, but recent evidences demonstrate that part of the damage may be due to the presence of the endometrioma itself. Indication to surgical treatment should balance the possible risks of damaging the ovarian reserve with the advantages of surgery in terms of satisfactory pain relief rates and pregnancy rates, and of obtaining tissue specimen for ruling out the rare cases of unexpected ovarian malignancy. A score system to guide the clinician in the decision to perform or withhold surgery is presented.
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http://dx.doi.org/10.1055/s-0036-1597126DOI Listing
January 2017
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