Obstetrics & Gynecology Email Alerts
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Obstetrics & Gynecology 2005;105:339-344
© 2005 by The American College of Obstetricians and Gynecologists
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Maso, G.
Right arrow Articles by Mandruzzato, G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Maso, G.
Right arrow Articles by Mandruzzato, G.
Related Collections
Right arrow General gynecology
Right arrow Gynecologic surgery

ORIGINAL RESEARCH

First-Trimester Intrauterine Hematoma and Outcome of Pregnancy

Gianpaolo Maso, MD, Giuseppina D'Ottavio, MD, Francesco De Seta, MD, Andrea Sartore, MD, Monica Piccoli, MD and Giampaolo Mandruzzato, MD

From the Department of Obstetrics and Gynecology, IRCCS Burlo Garofolo, University of Trieste, Trieste, Italy.

Address reprint requests to: Dr. Andrea Sartore, Department of Obstetrics and Gynecology, IRCCS Burlo Garofolo, University of Trieste, Via dell'Istria 65/1–34137, Trieste, Italy; e-mail: sartore{at}burlo.trieste.it.


   ABSTRACT
TOP
ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: To evaluate the outcome of pregnancies complicated by first-trimester intrauterine hematoma.

METHODS: An analysis was performed on 248 cases. The pregnancy outcome was correlated with hematoma volume, gestational age (weeks), and maternal age (years).

RESULTS: One hundred eighty-two cases were eligible for the study. Clinical complications occurred in 38.5% of the cases (adverse outcome group). Spontaneous abortion (14.3%), fetal growth restriction (7.7%), and preterm delivery (6.6%) were the most frequent clinical conditions observed. Considering the hematoma variables in adverse and favorable outcome groups, we found a significant difference only for gestational age at diagnosis. The median gestational age was significantly lower (P < .02) in the adverse outcome group (7.27, I and III quartiles 6.22–8.78) than in the favorable outcome cases (8.62, I and III quartiles 6.70–9.98). Among clinical conditions, the median gestational age was significantly lower (P = .02) in pregnancies complicated by spontaneous abortion (6.60, I and III quartiles 5.95–8.36) than in cases not ending in a miscarriage (8.50, I and III quartiles 6.70–9.91). The overall risk of adverse outcome was 2.4 times higher when the hematoma was diagnosed before 9 weeks (odds ratio 2.37, 95% confidence interval 1.20–4.70). In particular, intrauterine hematoma observed before 9 weeks significantly increases the risk of spontaneous abortion (odds ratio 14.79, 95% confidence interval 1.95–112.09)

CONCLUSION: Intrauterine hematoma can affect the outcome of pregnancy. The risk of spontaneous abortion is related to gestational age and is significantly increased if diagnosed before 9 weeks.

LEVEL OF EVIDENCE: III

Intrauterine hematoma is not an uncommon finding at ultrasound scanning in the early stages of pregnancies. Pre-existing medical conditions, autoimmune diseases, and immunological factors have been associated with intrauterine hematoma, but the etiology of this condition is still unknown. Intrauterine or subchorionic hematoma is defined as a collection of fluid in the uterine cavity, and it is believed to result from subchorionic bleeding caused by a partial detachment of the trophoblast from the uterine wall. This condition can be diagnosed only by ultrasonography. Mantoni and Pedersen6 first described its sonographic patterns. On ultrasound examination, it appears as an anechoic area that has a falciform shape, and it is usually observed behind or below the gestational sac, separating the chorion from the inner wall of the uterus. Small echogenic structures can be found in such areas, and they are believed to be blood clots.

The reported incidence of intrauterine hematoma has a wide range, between 0.5%7 and 22%,8 mainly associated with vaginal bleeding. The discrepancy in these rates might be related to different patient populations, study design, range of gestational ages, and lack of a standard definition. Moreover, the different approaches to ultrasound scanning, ie, transabdominal or transvaginal, may be a factor in this epidemiological issue.9

The clinical significance of this sonographic finding remains controversial, and observational studies focusing on this topic reported conflicting results.5 Many authors reported adverse outcome of pregnancy related to hematoma volume.6,10–13 Others observed that the subchorionic hematoma did not represent a risk factor for complications of pregnancy. Two large-series, controlled studies on unselected obstetric populations have been addressed to clarify this issue, concluding that this condition is significantly associated with adverse clinical conditions.17,18

The aim of our study was to investigate whether the volume of intrauterine hematoma observed in the first trimester of a viable pregnancy and 2 other variables (such as maternal age and gestational age at the time of the diagnosis) are predictive factors of adverse outcome.


   MATERIALS AND METHODS
TOP
ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
We reviewed the information from a 7-year period (1991–1997) collected from our database (tertiary referral center) on 248 unselected viable pregnancies with a history of vaginal bleeding/spotting and diagnosis of intrauterine hematoma. Patients’ informed consent to participate in the study was obtained in all the cases before the analysis. The study was exempt from institutional review board approval. All cases were diagnosed by transvaginal sonography (Acuson XP10 System, transducer 5–7 MHz; Acuson Corporation, Mountain View, CA) in the first trimester of pregnancy (6–13 weeks of gestation). Gestational age was calculated on the basis of the last menstrual period and was corrected when the crown-rump length measurements were more than 7 days different from this. A hematoma was defined as previously described by Mantoni and Pedersen.6 The volumes of the hematomas were estimated by measuring the maximum transverse, antero-posterior, and longitudinal diameters, multiplying these values by a constant of 0.523.19 The management and follow up of the study cases were decided on the basis of the clinical and sonographic picture. However, when serial scans were performed, only the hematoma volume and the gestational age at the first examination were considered for the analysis. We included in our study only the cases with calculated hematoma volume and complete follow-up of pregnancy. Patients who underwent elective abortion and/or invasive procedures and cases with multiple pregnancies, recurrent miscarriage (defined as a history of 2 or more consecutive first-trimester losses), uterine pathology (myomas), and malformations were excluded. The outcome of pregnancy was defined as adverse if one of the following conditions was present:

  1. Spontaneous abortion, defined as loss before 20 weeks of gestation;
  2. Fetal growth restriction, defined as birth weight of less than the tenth percentile for gestational age according to our population norms;
  3. Intensive care for threatened preterm delivery, defined as need of admission and tocolytic therapy;
  4. Preterm delivery, defined as delivery before 37 weeks of gestation;
  5. Placental abruption, defined as a clinically relevant event determined by the managing physician; or
  6. Fetal distress, defined as abnormal fetal heart monitoring traces or fetal blood sampling suggestive of hypoxemia/acidemia.

Outcome of pregnancy was first evaluated according to hematoma volume (milliliters), gestational age (weeks), and maternal age at the time of diagnosis (years).

In the second part of the study, we tested the results of Bennett et al,10 who found that large intrauterine hematoma volume, advanced maternal age (> 35 years), and early gestational age at diagnosis (< 9 weeks) might affect adversely the outcome of pregnancy. Our evaluation of the size of the hematoma was different from the one proposed by Bennett, who defined the size of the hematoma as the degree of the gestational sac circumference elevated by the hematoma. We arbitrarily stratified the hematoma volumes as small, medium, and large, according to volume values, respectively, of less than 1 mL, between 1 and 10 mL, and larger than 10 mL.

All statistical evaluations were performed with SPSS 11.5 statistical software (SPSS Inc, Chicago, IL). The Student t test was used to compare continuous variables between the groups. When the Kolmogorov-Smirnov normality test failed (P = .05), the Mann-Whitney rank sum test was used. The univariate association between the variables of the hematoma and the outcome of pregnancy was assessed by computing the corresponding odds ratios (ORs) for prevalence data and, when necessary, by Fisher exact test. The null hypothesis was rejected with {alpha} equal to 0.05.


   RESULTS
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
One hundred eighty-two cases (73.4%) met the inclusion criteria for the analysis. The mean maternal age (± standard deviation [SD]) was 30.7 years (± 4.8) (range 19.6–44), the median of the hematoma volume at the diagnosis was 1.36 mL (I quartile 0.48 mL, III quartile 3.38 mL; range 0.002–103.6 mL), and the mean gestational age (± SD) at diagnosis was 8.2 weeks (± 2.1) (range 5.3–13.1). Of the cases, 67.6% (123/182) were diagnosed before 9 weeks of gestation. Clinical complications occurred in 38.5% of the cases (70/182). Table 1 shows the distribution and rates of the clinical conditions observed in our cases: spontaneous abortion (14.3%), fetal growth restriction (7.7%), and preterm delivery (6.6%) were the most frequent.


View this table:
[in this window]
[in a new window]
  		Table 1. Intrauterine Hematoma and Associated Clinical Conditions

 

Considering the hematoma volumes, maternal age, and gestational age at diagnosis in adverse and favorable groups, we found a significant difference only for gestational age at diagnosis. The median gestational age was significantly lower overall in the adverse outcome group than in the favorable outcome cases (Table 2). When we separately analyzed every complication, a correlation was found only between gestational age at diagnosis and spontaneous abortion: a significantly earlier median gestational age was observed in cases complicated by spontaneous abortion (Table 2).


View this table:
[in this window]
[in a new window]
  		Table 2. Outcome of Pregnancy and Characteristics of Intrauterine Hematoma

 

Using the cutoff values for the intrauterine hematoma variables according to Bennett et al,10 modifying the evaluation of the size, we did not find any difference of outcome considering the hematoma volumes. There was an increased rate of adverse pregnancy outcome for cases diagnosed at maternal age over 35 years, but this finding was not statistically significant (P = .052, Table 3). On the contrary, when we considered the gestational age at diagnosis, the overall risk of adverse outcome was 2.4 times higher in cases observed before 9 weeks (Table 3).


View this table:
[in this window]
[in a new window]
  		Table 3. Association Between Adverse Pregnancy Outcome and Subchorionic Hematoma Variables

 

Once again, when we considered separately every single complication, we only observed a statistically significant correlation between spontaneous abortion and gestational age at diagnosis. Spontaneous abortion occurred in 20.3% of the cases diagnosed before 9 weeks, whereas the rate of this specific complication for the cases diagnosed after this gestational age was only 1.7%.

To avoid potential bias, adjusted odds ratios for outcome of pregnancy and spontaneous abortion were calculated with a logistic regression model including the hematoma volume, maternal age, and gestational age at diagnosis. The results were comparable to univariate analysis (crude odds ratios).


   DISCUSSION
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The relationship between clinical symptoms (pelvic pain/bleeding), clinical and sonographic features of intrauterine hematoma (gestational age at the time of diagnosis, maternal age at diagnosis, size/volume of the hematoma), and the outcome of pregnancy has been differently and separately investigated in the majority of the studies, with conflicting results being reported. Only Ball et al,17 in their large case-control study, evaluated the prognostic significance of clinical bleeding and intrauterine hematoma variables, drawing no definitive conclusions.

Our observational study on symptomatic cases affected by this condition was unique in investigating together the subchorionic hematoma variables to address whether the maternal age and characteristics related to intrauterine hematoma (the gestational age at the time of diagnosis, volume of the hematoma) might be predictive of a different outcome of pregnancy. Maternal age and gestational age at the time of diagnosis are possible prognostic factors in pregnancies complicated by subchorionic hematoma. It is nevertheless important to consider that both advanced maternal age and early gestational ages, independently of the presence of the intrauterine hematoma, are known to be significantly associated with an increased risk of spontaneous abortion, mainly related to chromosomal or structural fetal anomalies.20 Therefore, these variables might be considered risk factors per se, independently of the presence or absence of hematoma.

Dealing with subchorionic hematoma and maternal age, Bennett et al10 observed that the spontaneous abortion rate was approximately twice as high for women aged 35 years or older as for younger women (13.8% and 7.3%, respectively). Our results demonstrated a correlation between adverse outcome/spontaneous abortion rate and advanced maternal age, but this did not reach statistical significance, probably because of the low power of the study.

Gestational age at diagnosis is the other variable rarely considered in the studies dealing with this topic. Our results are similar to those observed in the retrospective study by Bennett et al10 of 516 cases complicated by subchorionic hematoma and focusing on spontaneous abortion risk. In our experience, using the same gestational-age cutoff, we observed that the risk of spontaneous abortion is nearly 15 times greater for cases diagnosed before 9 weeks of gestation than for those observed after this period. This observation can be helpful to the clinician in the risk assessment of the pregnancy complicated by intrauterine hematoma, bearing in mind that a diagnosis made before 9 weeks gives a 20% likelihood of miscarriage, whereas this possibility is far more remote (less than 2%) when the hematoma is diagnosed after this cutoff gestational age.

Finally, one of the features that could more directly influence the pregnancy outcome is hematoma volume. Doppler studies revealed a significant relationship between hematoma enlargement and the reduction of blood flow velocities in spiral arteries, with a potential threat to the continuance of the pregnancy by a direct pressure-volume effect.21

The results from available studies on hematoma volume and pregnancy outcome are again controversial. Many observational reports revealed a significant correlation between "large" hematomas and adverse outcome of pregnancy,6,10–13 while others failed to demonstrate this association (Jakab A Jr, Juhasz B, Toth Z. Outcome of the first trimester subchorial hematoma [abstract]. Tenth International Congress, The Fetus as a Patient. Brijuni, Croatia; 1994. p. 54). In our study, the median hematoma volume was not significantly different in adverse outcome and favorable outcome groups (P = .49). Moreover, no correlation with pregnancy outcome has been observed when hematoma volume was arbitrarily stratified as "small," "medium," and "large." Our results differed from those of Bennett et al10 who found that large volumes, defined as a degree larger than the 2/3 of the gestational sac circumference elevated by the hematoma, increased 2.4-fold the risk of spontaneous abortion. This difference might be due to our arbitrary definition of hematoma "size," giving the "absolute" value of hematoma, without relating it to the size of the gestational sac. However, we did not find any correlation with pregnancy outcome when the stratified volumes were matched with every single gestational week (our unpublished data). These different results might be also the consequence of our limited sample size or might be explained by considering that the majority of our cases showed small hematomas (volumes < 5 mL were observed in 87.1% of the cases).

Alternatively, the explanation for these discrepancies on this variable might be addressed by considering the physiopathological mechanism of formation of the subchorionic hematoma. In fact, the size might be the final result of 2 processes: the amount of subchorionic bleeding and the amount of the bleeding through the cervix. Therefore, the size of the hematoma may not represent a reliable estimation of the overall severity of the process, which could ultimately be calculated only by knowing the total amount of blood collected in the uterus, reabsorbed, and lost through the cervix. On this basis, therefore, it might be postulated that the presence and location of a hematoma, as a sign of the impaired placentation, rather than its volume, is important for pregnancy outcome.17

As in the majority of the studies on subchorionic hematomas, our data have mainly focused on the correlation between the characteristics of the hematoma and the risk of miscarriage. However, some controversial data have recently been reported in the literature about the risks of other late complications of pregnancy, such as stillbirth, abruptio placentae, preterm delivery, intrauterine growth restriction, fetal distress, and preeclampsia,17,18 when intrauterine hematoma is diagnosed (Table 4). Many of these clinical conditions are a consequence of impaired placentation, and it might be postulated that the presence of a subchorionic hematoma in early stages affects the normal process of trophoblast invasion.


View this table:
[in this window]
[in a new window]
  		Table 4. Review of Literature on Intrauterine Hematomas

 

Given the absence of a control group, it is not possible to estimate in our study the relative risk of pregnancy complications in patients with intrauterine hematoma. Moreover, because of our limited sample size, it has not been possible to have a reliable estimation of the association between the presence of this condition and the unfavorable pregnancy outcomes other than the spontaneous abortion. Nevertheless, our observational study gave an overall incidence of pregnancy complications in these patients as high as roughly 40%, without including all the possible clinical adverse conditions due to a lack of data.

From our results it is not possible to draw definitive conclusions to all the unanswered questions about the short- and long-term effects of subchorionic hematoma in pregnancy. However, our study demonstrated that, in the presence of this finding and clinical bleeding, the prognosis of pregnancy is significantly related to the gestational age at the time of diagnosis, whereas the size of the hematoma does not seem to have a clinical significance. This might be useful for caregivers in appropriately counseling the patient about the short-term outcome of pregnancy and, particularly, about the risk of miscarriage.


   Footnotes
 
The authors thank Dr. Sandro Zicari, University of Trieste, for his assistance with the statistical analysis of data and Drs. Giancarlo Conoscenti and Mariangela Rustico fortheir contribution in preparing the manuscript.

Received May 31, 2004. Received in revised form July 31, 2004. Accepted October 14, 2004.

doi:10.1097/01.AOG.0000152000.71369.bd


   REFERENCES
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
1. Heller DS, Rush D, Baergen RN. Subchorionic hematoma associated with thrombophilia: report of three cases. Pediatr Dev Pathol 2003;6:261–4.[Medline]

2. Alijotas J, Izquierdo M, Serra B, Cusido MT, Ribera M, Carrera JM. Antinuclear autoantibodies, complement level, hypergammaglobulinemia and spontaneous intrauterine hematoma in pregnant women. Am J Reprod Immunol 2003;50:1–6.

3. Baxi LV, Pearlstone MM. Subchorionic hematoma and the presence of autoantibodies. Am J Obstet Gynecol 1991;165:1423–4.[Medline]

4. Khong TY, Hague WM. The placenta in maternal hyperhomocysteinaemia. Br J Obstet Gynaecol 1999;106:273–8.[Medline]

5. Pearlstone MM, Baxi LV. Subchorionic hematoma: a review. Obstet Gynecol Surv 1993;48:65–8.[Medline]

6. Mantoni M, Pedersen JF. Intrauterine hematoma: an ultrasonic study of threatened abortion. Br J Obstet Gynaecol 1981;88:47–51.[Medline]

7. Seki H, Kuromaki K, Takeda S, Kinoshita K. Persistent subchorionic hematoma with clinical symptoms until delivery. Int J Gynaecol Obstet 1998;63:123–8.[Medline]

8. Borlum KG, Thomsen A, Clausen I, Eriksen G. Long term prognosis of pregnancies with intrauterine hematomas. Obstet Gynecol 1989;74:231–3.[Abstract/Free Full Text]

9. Dickey RP, Olar TT, Curole DN, Taylor SN, Matulich EM. Relationship of first-trimester subchorionic bleeding detected by color doppler ultrasound to subchorionic fluid, clinical bleeding, and pregnancy outcome. Obstet Gynecol 1992;80:415–20.[Medline]

10. Bennett GL, Bromley B, Lieberman E, Benacerraf BR. Subchorionic hemorrhage in first trimester pregnancies: prediction of pregnancy outcome with sonography. Radiology 1996;200:803–6.[Abstract/Free Full Text]

11. Sauerbrei EE, Pham DH. Placental abruption and subchorionic hemorrhage in the first half of pregnancy: US appearance and clinical outcome. Radiology 1986;160:109–12.[Abstract/Free Full Text]

12. Abu-Yousef MM, Bleicher JJ, Williamson RA, Weiner CP. Subchorionic hemorrhage: sonographic diagnosis and clinical significance. AJR Am J Roentgenol 1987;149:737–40.[Abstract/Free Full Text]

13. Mandruzzato GP, D'Ottavio G, Rustico MA, Fontana A, Bogatti P. The intrauterine hematoma: diagnostic and clinical aspects. J Clin Ultrasound 1989;17:503–10.[Medline]

14. Tower CL, Regan L. Intrauterine haematomas in a recurrent miscarriage population. Hum Reprod 2001;16:2005–7.[Abstract/Free Full Text]

15. Johns J, Hyett J, Jauniaux E. Obstetric outcome after threatened miscarriage with and without a hematoma on ultrasound. Obstet Gynecol 2003;102:483–7.[Abstract/Free Full Text]

16. Falco P, Milano V, Pilu G, David C, Grisolia N, Rizzo N, et al. Sonography of pregnancies with first trimester bleeding and viable embryo: a study of prognostic indicators by logistic regression analysis. Ultrasound Obstet Gynecol 1996;7:165–9.[Medline]

17. Ball RH, Ade CM, Schoenborn JA, Crane JP. The clinical significance of ultrasonographically detected subchorionic hemorrhages. Am J Obstet Gynecol 1996;174:996–1002.[Medline]

18. Nagy S, Bush M, Stone J, Lapinski RH, Gardo S. Clinical significance of subchorionic and retroplacental hematomas detected in the first trimester of pregnancy. Obstet Gynecol 2003;102:94–100.[Abstract/Free Full Text]

19. Stabile I, Campbell S, Grudzinskas JG. Ultrasonic assessment of complications during first trimester of pregnancy. Lancet 1987;2:1237–40.[Medline]

20. Makrydimas G, Daskalakis A, Souka AP, Kavalakis Y, Michalas S. Fetal loss following ultrasound diagnosis of a live fetus at 6–10 weeks of gestation. Ultrasound Obstet Gynecol 2003;22:368–72.[Medline]

21. Kupesic S, Kurjak A, Chervenak FA. Doppler studies of subchorionic hematomas in early pregnancy. In: Chervenak FA, Kurjak A, editors. Current perspectives on the fetus as a patient. New York (NY): The Parthenon Publishing Group; 1996. p. 33–8.

22. Goldstein SR, Subramanyam BR, Raghavendra BN, Horii SC, Hilton S. Subchorionic bleeding in threatened abortion: sonographic findings and significance. AJR Am J Roentgenol 1983;141:975–8.[Abstract/Free Full Text]

23. Pedersen JF, Mantoni M. Prevalence and significance of subchorionic hemorrhage in threatened abortion: a sonographic study. AJR Am J Roentgenol 1990;154:535–7.[Abstract/Free Full Text]

24. Jouppila P. Clinical consequences after ultrasonic diagnosis of intrauterine hematoma in threatened abortion. J Clin Ultrasound 1985;13:107–11.[Medline]

25. Nyberg DA, Mack LA, Benedetti TJ, Cyr DR, Schumann WP. Placental abruption and placental hemorrhage: correlation of sonographic findings with fetal outcome. Radiology 1987;164:357–61.[Abstract/Free Full Text]

26. Bloch C, Altchek A, Levy-Ravtech M. Sonography in early pregnancy: the significance of subchorionic hemorrhage. Mt Sinai J Med 1989;56:290–2.[Medline]

27. Ylostalo P, Ammala P, Seppala P. Intrauterine haematoma and placental protein 5 in patients with uterine bleeding during pregnancy. Br J Obstet Gynaecol 1984;91:353–6.[Medline]

28. Sharma G, Kalish RB, Chasen ST. Prognostic factors associated with antenatal subchorionic echolucencies. Am J Obstet Gynecol 2003;189:994–6.[Medline]

29. Williams MA, Mittendorf R, Leiberman E, Monson RR. Adverse outcome of pregnancy associated with first trimester vaginal bleeding. Obstet Gynecol 1991;78:14–8.[Abstract/Free Full Text]

30. Salafia CM, Lopez-zeno JA, Sherer DM, Whittington SS, Minior VK, Vintzileos AM. Histologic evidence of old intrauterine bleeding is more frequent in prematurity. Am J Obstet Gynecol 1995;173:1065–70.[Medline]

31. Laurini RN. Abruptio placentae: from early pregnancy to term. In: Chervenak FA, Kurjak A, editors. Current perspectives on the fetus as a patient. New York (NY): The Parthenon Publishing Group; 1996. p. 433–44.




This article has been cited by other articles:


Home page
 J Ultrasound MedHome page
J. Leite, P. Ross, A. C. Rossi, and P. Jeanty
Prognosis of Very Large First-Trimester Hematomas.
J. Ultrasound Med., November 1, 2006; 25(11): 1441 - 1445.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Maso, G.
Right arrow Articles by Mandruzzato, G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Maso, G.
Right arrow Articles by Mandruzzato, G.
Related Collections
Right arrow General gynecology
Right arrow Gynecologic surgery

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS