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Thyroid peroxidase antibodies may increase the risk of miscarriage and preterm birth. In this controlled trial, the use of levothyroxine before conception and through birth did not improve live-birth rates among euthyroid women with such antibodies and a history of miscarriage or infertility.

A young woman in her 20s presented with sudden onset right-sided abdominal pain. On examination she was tender in the right adnexae. Her urine pregnancy test was positive and βHCG value was 1862. Abdominal and pelvic ultrasound revealed evidence of a significant right-sided adnexal mass, a small amount of peritoneal-free fluid and an empty uterus. The decision was made to proceed with laparoscopy in view of mass size and the presence of fluid in the pelvis. Conservative resection of the gestational sac was performed and the patient made an uneventful recovery. Histology was consistent with ovarian ectopic pregnancy.

In this multicenter, randomized, double-blind, placebo-controlled trial involving women with vaginal bleeding in early pregnancy, treatment with progesterone during the first trimester did not result in a significantly higher incidence of live births than placebo.

The anti-progesterone drug mifepristone and the prostaglandin misoprostol can be used to treat missed miscarriage. However, it is unclear whether a combination of mifepristone and misoprostol is more effective than administering misoprostol alone. We investigated whether treatment with mifepristone plus misoprostol would result in a higher rate of completion of missed miscarriage compared with misoprostol alone. MifeMiso was a multicentre, double-blind, placebo-controlled, randomised trial in 28 UK hospitals. Women were eligible for enrolment if they were aged 16 years and older, diagnosed with a missed miscarriage by pelvic ultrasound scan in the first 14 weeks of pregnancy, chose to have medical management of miscarriage, and were willing and able to give informed consent. Participants were randomly assigned (1:1) to a single dose of oral mifepristone 200 mg or an oral placebo tablet, both followed by a single dose of vaginal, oral, or sublingual misoprostol 800 μg 2 days later. Randomisation was managed via a secure web-based randomisation program, with minimisation to balance study group assignments according to maternal age (<30 years vs ≥30 years), body-mass index (<35 kg/m2vs ≥35 kg/m2), previous parity (nulliparous women vs parous women), gestational age (<70 days vs ≥70 days), amount of bleeding (Pictorial Blood Assessment Chart score; ≤2 vs ≥3), and randomising centre. Participants, clinicians, pharmacists, trial nurses, and midwives were masked to study group assignment throughout the trial. The primary outcome was failure to spontaneously pass the gestational sac within 7 days after random assignment. Primary analyses were done according to intention-to-treat principles. The trial is registered with the ISRCTN registry, ISRCTN17405024. Between Oct 3, 2017, and July 22, 2019, 2595 women were identified as being eligible for the MifeMiso trial. 711 women were randomly assigned to receive either mifepristone and misoprostol (357 women) or placebo and misoprostol (354 women). 696 (98%) of 711 women had available data for the primary outcome. 59 (17%) of 348 women in the mifepristone plus misoprostol group did not pass the gestational sac spontaneously within 7 days versus 82 (24%) of 348 women in the placebo plus misoprostol group (risk ratio [RR] 0·73, 95% CI 0·54–0·99; p=0·043). 62 (17%) of 355 women in the mifepristone plus misoprostol group required surgical intervention to complete the miscarriage versus 87 (25%) of 353 women in the placebo plus misoprostol group (0·71, 0·53–0·95; p=0·021). We found no difference in incidence of adverse events between the study groups. Treatment with mifepristone plus misoprostol was more effective than misoprostol alone in the management of missed miscarriage. Women with missed miscarriage should be offered mifepristone pretreatment before misoprostol to increase the chance of successful miscarriage management, while reducing the need for miscarriage surgery. UK National Institute for Health Research Health Technology Assessment Programme.

To describe the prevalence of and factors associated with different thyroid dysfunction phenotypes in women who are asymptomatic preconception. Observational cohort study. A total of 49 hospitals across the United Kingdom between 2011 and 2016. Women aged 16 to 41years with history of miscarriage or subfertility trying for a pregnancy. Prevalences and 95% confidence intervals (CIs) were estimated using the binomial exact method. Multivariate logistic regression analyses were conducted to identify risk factors for thyroid disease. None. Rates of thyroid dysfunction. Thyroid function and thyroid peroxidase antibody (TPOAb) data were available for 19213 and 19237 women, respectively. The prevalence of abnormal thyroid function was 4.8% (95% CI, 4.5-5.1); euthyroidism was defined as levels of thyroid-stimulating hormone (TSH) of 0.44 to 4.50 mIU/L and free thyroxine (fT4) of 10 to 21 pmol/L. Overt hypothyroidism (TSH > 4.50 mIU/L, fT4 < 10 pmol/L) was present in 0.2% of women (95% CI, 0.1-0.3) and overt hyperthyroidism (TSH < 0.44 mIU/L, fT4 > 21 pmol/L) was present in 0.3% (95% CI, 0.2-0.3). The prevalence of subclinical hypothyroidism (SCH) using an upper TSH concentration of 4.50 mIU/L was 2.4% (95% CI, 2.1-2.6). Lowering the upper TSH to 2.50 mIU/L resulted in higher rates of SCH, 19.9% (95% CI, 19.3-20.5). Multiple regression analyses showed increased odds of SCH (TSH > 4.50 mIU/L) with body mass index (BMI) ≥ 35.0 kg/m2 (adjusted odds ratio [aOR] 1.71; 95% CI, 1.13-2.57; P = 0.01) and Asian ethnicity (aOR 1.76; 95% CI, 1.31-2.37; P < 0.001), and increased odds of SCH (TSH ≥ 2.50 mIU/L) with subfertility (aOR 1.16; 95% CI, 1.04-1.29; P = 0.008). TPOAb positivity was prevalent in 9.5% of women (95% CI, 9.1-9.9). The prevalence of undiagnosed overt thyroid disease is low. SCH and TPOAb are common, particularly in women with higher BMI or of Asian ethnicity. A TSH cutoff of 2.50 mIU/L to define SCH results in a significant proportion of women potentially requiring levothyroxine treatment.

Chronic pelvic pain affects 2–24% of women worldwide and evidence for medical treatments is scarce. Gabapentin is effective in treating some chronic pain conditions. We aimed to measure the efficacy and safety of gabapentin in women with chronic pelvic pain and no obvious pelvic pathology. We performed a multicentre, randomised, double-blind, placebo-controlled randomised trial in 39 UK hospital centres. Eligible participants were women with chronic pelvic pain (with or without dysmenorrhoea or dyspareunia) of at least 3 months duration. Inclusion criteria were 18–50 years of age, use or willingness to use contraception to avoid pregnancy, and no obvious pelvic pathology at laparoscopy, which must have taken place at least 2 weeks before consent but less than 36 months previously. Participants were randomly assigned in a 1:1 ratio to receive gabapentin (titrated to a maximum dose of 2700 mg daily) or matching placebo for 16 weeks. The online randomisation system minimised allocations by presence or absence of dysmenorrhoea, psychological distress, current use of hormonal contraceptives, and hospital centre. The appearance, route, and administration of the assigned intervention were identical in both groups. Patients, clinicians, and research staff were unaware of the trial group assignments throughout the trial. Participants were unmasked once they had provided all outcome data at week 16–17, or sooner if a serious adverse event requiring knowledge of the study drug occurred. The dual primary outcome measures were worst and average pain scores assessed separately on a numerical rating scale in weeks 13–16 after randomisation, in the intention-to-treat population. Self-reported adverse events were assessed according to intention-to-treat principles. This trial is registered with the ISRCTN registry, ISCRTN77451762. Participants were screened between Nov 30, 2015, and March 6, 2019, and 306 were randomly assigned (153 to gabapentin and 153 to placebo). There were no significant between-group differences in both worst and average numerical rating scale (NRS) pain scores at 13–16 weeks after randomisation. The mean worst NRS pain score was 7·1 (standard deviation [SD] 2·6) in the gabapentin group and 7·4 (SD 2·2) in the placebo group. Mean change from baseline was −1·4 (SD 2·3) in the gabapentin group and −1·2 (SD 2·1) in the placebo group (adjusted mean difference −0·20 [97·5% CI −0·81 to 0·42]; p=0·47). The mean average NRS pain score was 4·3 (SD 2·3) in the gabapentin group and 4·5 (SD 2·2) in the placebo group. Mean change from baseline was −1·1 (SD 2·0) in the gabapentin group and −0·9 (SD 1·8) in the placebo group (adjusted mean difference −0·18 [97·5% CI −0·71 to 0·35]; p=0·45). More women had a serious adverse event in the gabapentin group than in the placebo group (10 [7%] of 153 in the gabapentin group compared with 3 [2%] of 153 in the placebo group; p=0·04). Dizziness, drowsiness, and visual disturbances were more common in the gabapentin group. This study was adequately powered, but treatment with gabapentin did not result in significantly lower pain scores in women with chronic pelvic pain, and was associated with higher rates of side-effects than placebo. Given the increasing reports of abuse and evidence of potential harms associated with gabapentin use, it is important that clinicians consider alternative treatment options to off-label gabapentin for the management of chronic pelvic pain and no obvious pelvic pathology. National Institute for Health Research.

We describe a case of group A streptococcal toxic shock syndrome (TSS) associated with pelvic peritonitis, occurring after a diagnostic hysteroscopy and curettage in a healthy woman. At laparotomy, performed to rule out bowel perforation, the diagnosis of pelvic inflammatory disease and pelvic peritonitis was confirmed. Her general condition deteriorated postoperatively needing supportive care in the intensive care unit, followed by gradual recovery. Although it is difficult to avoid a laparotomy in most cases following a surgical procedure, it is important to consider the diagnosis of streptococcal TSS associated with pelvic peritonitis from ascending sepsis in rapid onset, severely shocked cases.

BACKGROUND Thyroid peroxidase antibodies are associated with increased risk of miscarriage and preterm birth, even when thyroid function is normal. Small trials indicate levothyroxine could reduce such adverse outcomes. METHODS We conducted a double-blind, placebo-controlled trial to investigate whether levothyroxine treatment would increase live birth rates among euthyroid women with thyroid peroxidase antibodies and a history of miscarriage or infertility. We randomly assigned women to receive 50mcg daily of levothyroxine or placebo, commenced preconception and continued until the end of pregnancy. The primary outcome was live birth ≥34 weeks gestation. RESULTS We tested 19,585 women for thyroid peroxidase antibodies and thyroid function across 49 hospitals in the United Kingdom. A total of 952 women were randomly assigned to receive either levothyroxine (476) or placebo (476). The follow-up rate for the primary outcome was 98.7% (940/952). A pregnancy was achieved in 266/470 (56.6%) in the levothyroxine group and 274/470 (58.3%) in the placebo group. The live birth rate in the levothyroxine group was 37.4% (176/470) versus 37.9% (178/470) in the placebo group (relative risk, 0.97; 95% confidence interval [CI], 0.83 to 1.14, p=0.74; absolute risk difference, -0.4%; 95% CI, -6.6% to 5.8%). There were no significant differences in other pregnancy outcomes, including the rates of pregnancy loss, preterm birth, or in neonatal outcomes. Serious adverse events occurred in 6% of women in the levothyroxine group and 4% in the placebo group (p=0.14). CONCLUSION Treatment with levothyroxine in euthyroid women with thyroid peroxidase antibodies did not increase the rate of live births. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

The success of second-generation endometrial ablation performed as day case or outpatient procedure is often hampered by severe postoperative pain. We administered dilute bupivacaine solution into the uterine cavity soon after balloon ablation in ten consecutive women, looking at the safety profile of bupivacaine. Three hours postoperative serum bupivacaine levels were well below the toxic level in all women with no side effects reported.

A young woman in her 20s presented with sudden onset right-sided abdominal pain. On examination she was tender in the right adnexae. Her urine pregnancy test was positive and βHCG value was 1862. Abdominal and pelvic ultrasound revealed evidence of a significant right-sided adnexal mass, a small amount of peritoneal-free fluid and an empty uterus. The decision was made to proceed with laparoscopy in view of mass size and the presence of fluid in the pelvis. Conservative resection of the gestational sac was performed and the patient made an uneventful recovery. Histology was consistent with ovarian ectopic pregnancy.