Hilary R. Haber’s research while affiliated with Harvard Medical School and other places

Purpose of review: Retained products of conception (POC) may occur independently or as a consequence of placenta accreta spectrum (PAS). Managing these conditions depends on the clinical scenario, and in some cases, can involve the use of minimally invasive techniques. This review presents the role of hysteroscopy and laparoscopy in the treatment of retained POC and the adherent placenta. Recent findings: Hysteroscopic resection of retained POC is reported to have favorable outcomes compared to blind dilation and curettage, including higher success rates and a lower risk of intrauterine adhesion formation. Hysteroscopic and laparoscopic techniques for managing PAS are limited to select cases where uterine preservation is desired, or a laparoscopic gravid or postpartum delayed hysterectomy is feasible. Data on these methods are limited to case reports. Summary: A hysteroscopic approach is preferred over dilation and curettage for retained POC. Minimally invasive surgery may have a role in unique cases of PAS.

Background Induction of labor is very common in the United States. Multiple prior studies have tried to outline a faster time to delivery to improve maternal and fetal outcomes. Objective To evaluate whether women who undergo labor induction with single balloon catheter and oxytocin have a shorter time to delivery with planned removal at six vs. twelve hours. Study Design In this randomized controlled trial, labor induction was performed using combination single balloon catheter and oxytocin. Term women, both nulliparous and multiparous, aged 18-50 years old with cephalic singletons were included if they were undergoing induction of labor with a Bishop score less than six and cervical dilation less than 2cm. Women were randomized to planned removal of the single balloon catheter at six compared with twelve hours. The primary outcome was time from catheter insertion to delivery. We were powered to show a four-hour time difference with a sample size of 89 women per group (n=178). Planned sensitivity analyses were performed to account for cesarean delivery in labor. Results From February 2019-June 2020, 237 women were screened, 178 were randomized and 177 included in the final analysis (89 in the six-hour group, 88 in the twelve-hour group). Insertion to delivery time was significantly shorter in the six-hour group (19.2 vs. 24.3 hours, p=0.04) and the proportion of women delivered by twenty-four hours was significantly greater in the six-hour group (67.4% vs 47.4%; p<0.01). There was no difference in Bishop score at removal or secondary maternal or neonatal outcomes. In a Cox Proportional Hazard model censoring for cesarean delivery, the six-hour group had a significantly shorter insertion to delivery time (HR 0.67, p=0.02). Conclusion Labor induction with a single balloon catheter and oxytocin with planned removal at six rather than twelve hours, results in a shorter time from insertion to delivery without increasing cesarean delivery. Decreasing the length of time a single balloon catheter is in place should be considered in clinical protocols.

Objective Morcellation is the technique to remove large specimens via small incisions and is commonly used in gynecologic procedures. In this video we demonstrate contained manual morcellation techniques in benign gynecologic surgeries. Design Stepwise demonstration of four techniques with narrated video footage. Setting Tertiary academic teaching hospital. Interventions This video showcases four contained manual morcellation techniques: abdominal extraction via an umbilical “mini-laparotomy” incision, abdominal extraction via a suprapubic “mini-laparotomy” incision, transvaginal extraction through the colpotomy and transvaginal extraction through posterior cul-de-sac with uterus in place. A particular strategy should be selected based on appropriate patient characteristics and surgical factors. Conclusion Minimizing risk during tissue extraction is critical to minimally invasive procedures. The morcellation techniques displayed in this video allow for tissue extraction via small incisions while reducing the risk of spreading an undiagnosed malignancy.