Prawn sandwiches, red herrings and abdominal pregnancy

An unusual presentation of abdominal pregnancy is reported. The difficulty in diagnosis of this form of ectopic pregnancy, and the potential risks of delayed intervention are highlighted. The association with uterine anomaly, in this case uterus didelphys, is discussed.

Cervical pregnancy--a forgotten entity in family practice

BACKGROUND

Cervical pregnancy is a rare form of ectopic pregnancy that is associated with considerable maternal morbidity and a high mortality rate if early diagnosis and treatment are not carried out in a timely fashion.

METHODS

The current medical literature was reviewed by searching MEDLINE files from 1985 to 1996, using the key words "ectopic pregnancy" and "cervical pregnancy." Older articles were accessed from cross-reference of the more recent publications.

RESULTS

The incidence of cervical pregnancy is 1 in 2400 deliveries and represents less than 1.0 percent of all ectopic pregnancies. No clear cause of cervical pregnancy has been described, and criteria for the clinical, pathologic, and sonographic diagnosis have been well established. The most common clinical complaint is painless vaginal bleeding. Routine transvaginal sonography early on allows for conservative management and avoids adverse outcomes. Methotrexate administered systemically and by intra-amniotic instillation are the therapeutic options of choice. Gestational age and the presence or absence of fetal cardiac activity are major prognostic factors for its success.

CONCLUSION

Earlier diagnosis of cervical pregnancy using sonography and conservative management of this condition have reduced considerably the morbidity and mortality associated with this rare form of ectopic pregnancy and have helped preserve a woman's future fertility.

[The evaluation of the efficiency of treatment in ectopic pregnancy with the application of various surgical procedures]

In our study we analyzed 54 women with confirmed diagnosis of ectopic pregnancy, in whom two different surgical approaches were performed. There were 40 salpingotomies and 14 salpingectomies. The dynamics of the decrease of beta hCG serum level were assessed. The beta hCG levels not greater than 5 mIU/ml (2nd IS) were the markers of the recovery. Similar therapeutic effect was obtained in both testing group. The normalisation of the beta hCG serum level was observed after 19th and 21st days after salpingectomy and salpingotomy, respectively.

Spontaneous left tubal and right interstitial pregnancy. A case report

BACKGROUND

Spontaneous bilateral ectopic pregnancy is a rare event and difficult to diagnose preoperatively.

CASE

A unique case occurred of bilateral ectopic pregnancy involving the left fallopian tube and right cornu, or interstitial segment.

CONCLUSION

This case demonstrates the difficulty in diagnosing heterotopic pregnancies and in particular those pregnancies with an interstitial component and also demonstrates the limits of ultrasound and laparoscopy in making such a diagnosis.

Pseudocholinesterase hyperactivity with succinylcholine resistance: an unusual cause of difficult intubation

We describe a case of difficult intubation, possibly due to marked pseudocholinesterase hyperactivity that caused rapid inactivation of succinycholine. Possible causes of difficult intubation and pseudocholinesterase hyperactivity are discussed. Literature on genetic variants associated with markedly increased pseudocholinesterase activity are reviewed. It is concluded that pseudocholinesterase hyperactivity may be a rare cause of difficult intubation. We recommend that pseudocholinesterase activity should be determined in all patients who appear to be resistant to the action of normal doses of succinylcholine or mivacurium.

Subcutaneous emphysema and pneumothorax during laparoscopy for ectopic pregnancy removal

We report a case of subcutaneous emphysema and pneumothorax during laparoscopic removal of ectopic pregnancy. Increases in airway pressures and end-tidal carbon dioxide, simultaneously with decrease of lung compliance, led quickly to diagnosis of pneumothorax. We recommend a careful monitoring of these variables during laparoscopic procedures. Carbon dioxide pneumothorax can occur even without pulmonary or pleural trauma.

A new laparoscopic technique for interstitial pregnancy resection. A case report

BACKGROUND

The interstitial gestation prevalence ranges from 1 in 2,500-5,000 live births, with a mortality rate of 2-2.5%. Total abdominal hysterectomy is usually offered to clinically stable patients over 35 years old. For younger women who desire to preserve their child-bearing capacity, interstitial pregnancy excision with a salpingo-oopherectomy is offered. The case presented here differed from the classic approach in that the adnexal structures were preserved, the products of conception were excised laparoscopically, and myometrium reconstruction was performed by suturing and tying with a laparoscopic technique.

CASE

A 34-year-old multipara presented with genital tract bleeding and gradual-onset, diffuse pelvic cramps progressively worsening and associated with nausea and vomiting. As expected, the regular, last menstrual period was 8 weeks prior to the patient's hospital admission. The serum beta-human chorionic gonadotropin level was 20,159 mIU/mL and the progesterone level 12.6 ng/mL. High-resolution transvaginal ultrasound revealed no intrauterine gestational sac. A 1.2-cm fluid collection was observed in the right uterine cornual area, and posterior cul-de-sac fluid was present. A hysteroscopic evaluation was inconclusive, and the endometrium frozen section histologic study failed to confirm the presence of chorionic villi. The patient underwent diagnostic and operative laparoscopic excision of the interstitial pregnancy with adnexa preservation.

CONCLUSION

Laparoscopic resection of interstitial pregnancy with the preservation of the adnexal structures was a safe alternative to laparotomy in this case.

Ultrasonography and magnetic resonance imaging findings in a patient with an unruptured interstitial pregnancy

We report a case of an unruptured interstitial pregnancy, which showed characteristic ultrasonographic and magnetic resonance imaging (MRI) findings. Color and pulsed Doppler sonography may facilitate early diagnosis of interstitial pregnancy. MRI may play some role in the diagnosis of this entity when ultrasound studies are insufficient or equivocal.

A case of pregnancy in a woman with cloacal dysgenesis and a rudimentary uterine horn

Cloacal dysgenesis is frequently associated with uterine anomalies. We report a case of pregnancy which resulted in an abortion in a woman with a persistent cloaca. Presumptive diagnosis before operation was ectopic pregnancy of the left tube. Postoperatively, the site of implantation of the conceptus was found to be the cavity of a unicornuate uterus in association with a rudimentary horn, the presence of which misled us to diagnose an ectopic pregnancy.

[Urinary complications during laparoscopy: a urachal diverticula injury]

The authors report a bladder injury during laparoscopic procedure. A laparotomy is performed immediately and shows an urachal anomaly with the bladder reaching the umbilic. One of the accessory trocars perforates the bladder in its unusual position. Surgical repair is made and the patient discharged without sequelae 12 days later. Rate of bladder injury increases with development of advanced laparoscopy as Burch and hysterectomy. Careful drainage with folley catheter during all laparoscopic procedures present greater than morbidity. Previous laparotomy may change the usual position of the bladder. Care must be taken in case of wall anomalies as in our observation. Per-operative suspicion of bladder injury (hematuria, presence of gas in the urinary catheter collection bag) can be proved with the injection of methylene blue in the folley catheter. Laparoscopic repair is possible for an experienced surgeon, associated with 10 days continuous urinary drainage and quinolone antibiotherapy. Morbidity of unknown bladder injury is great with some death-case reports. All diagnosis technique possible must be used to light these clinical situations, urinary peritonitis symptomatology is often non specific.

Doppler findings in chronic ectopic pregnancy: case report

Chronic ectopic pregnancy is an uncommon form of tubal pregnancy manifested as a pelvic mass with minimal symptoms and a low or absent titer of human chorionic gonadotropin. For this reason, most of the reported cases have been diagnosed only after explorative laparotomy. The value of Doppler ultrasonography for preoperative diagnosis of this entity has not yet been established. We report on a 36-year-old patient who was admitted for intermittent right lower quadrant abdominal pain of 3 months' duration, and a right adnexal mass found on pelvic examination. On Doppler ultrasonography, a right complex adnexal mass was demonstrated, characterized by extensive external vascularization, aberrant vessels and arteriovenous shunting, but with no internal blood flow. Explorative laparotomy revealed a right tubal mass adherent to the omentum, and covered by numerous enlarged and tortuous blood vessels originating in the omentum. Pathological examination of the mass revealed a chronic ectopic pregnancy. The possible contribution of Doppler-specific characteristics for the diagnosis of chronic ectopic pregnancy is described and discussed.

[Management of ectopic pregnancies at the university clinic of gynecology and obstetrics in Cotonou (Benin)]

In 1993 and 1994, there were 223 cases of ectopic pregnancy, resolved by surgery, at the University Clinic of Gynecology and Obstetrics of the National Teaching Hospital in Cotonou. This represents 4.57% of the number of deliveries. The study of 204 cases reveals the following characteristics: (i) There are clinical signs: pelvic pains and/or metrorrhagia in 97% of cases; (ii) Diagnosis was often late with a hemoperitoneum and required major intervention (salpingectomy). Ultrasound scanning allowed accurate diagnosis in 30.39% of cases. Celioscopy was necessary in 3.92% of cases; (iii) The life prognosis is usually good (1 death in 204 cases; i.e. 0.49%). The functional prognosis is difficult to estimate. The evolution of medical techniques, with the help of ultrasound scans facilitates early diagnosis and application of modern less traumatic therapies such as endoscopic surgery and conservative treatment.

[Initial experience of 878 patients with operative gynecologic laparoscopy]

OBJECTIVE

To recommend the operative laparoscopic techniques for gynecology.

METHODS

Proper application of the technical skills was described on the basis of 878 operations performed laparoscopically. These skills were divided into three groups: level I endocoagulation in 124 cases; level II pretied ligature placement and aquadissection in 653 cases; level III electrosection, electrocoagulation and knottying, suturing in 101 cases.

RESULTS

A total of 866 operations were completed laparoscopically without major intraoperative complications. Twelve cases were converted to laparotomy due to difficulties. The mean operating time for level I, level II and level III group was 49 minutes, 77 minutes and 171 minutes respectively. The incidence of febrile mobidity for level I, level II and level III group was 0.0%, 4.8% and 33.3% respectively. There was one case of postoperative haemorrhage associated with infection in the level III group. However, no major post-operative complications occurred in the level I-II group and the clinical outcome including the overall patients satisfaction was good.

CONCLUSION

Mastery of operative laparoscopic techniques step by step along with the degree of surgical difficulty is madatory, and can deliver optimal clinical outcome hopefully. It will also help to expand the use of operative gynecologic laparoscopy in a safe and effective way.

Ectopic pregnancy: let's cut! Strict laparoscopic approach to 194 consecutive cases and review of literature on alternatives

From March 1989 to December 1995, 194 cases of ectopic pregnancy were diagnosed in our centre and treated following a strict laparoscopic protocol. A total of 193 cases was treated surgically and only one case was treated medically, because general anaesthesia was contraindicated. Altogether, eight laparotomies (4.1%) had to be performed; three primary and five secondary, due to uncontrollable haemorrhage (n = 3) and too large pregnancy size (n = 2). Peri- or postoperative complications were encountered in 24 cases (12.4%). Residual disease occurred in 14 cases (7.2%), all after a technically successful operative laparoscopic procedure. These cases received adjuvant therapy, either systemic administration of methotrexate or a second intervention. The overall laparoscopic cure rate was 88.1% (171/194). Conclusive follow-up data could be obtained concerning 110 cases with an active desire for pregnancy. Overall conception rate was 77.3%, with an ongoing pregnancy rate of 81.2% and a recurrency rate of 10.6%. A critical overview of the available data on non-surgical approaches is made, while the reported results are evaluated according to published data. It is concluded that at this stage a surgical approach by means of operative laparoscopy should remain the gold standard in treating ectopic pregnancies.

Ovarian pregnancy and operative laparoscopy: report of eight cases

We report a series of eight cases of ovarian pregnancy treated by operative laparoscopy during the last 12 years. This rare ectopic pregnancy (2.6% of all extra-uterine pregnancies in our experience) is difficult to diagnose prior to surgery. Earlier diagnosis is now possible, owing to the availability of highly specific radioimmunoassay for human chorionic gonadotrophin and the development of transvaginal ultrasonography. Primary ovarian pregnancy is distinguished by some authors from distal tubal pregnancy, in which a secondary ovarian implantation is possible. The therapy is surgical and currently more conservative than in the past, because of improvement in operative laparoscopy. Laparoscopy allows a short hospital stay, less physical stress and a favourable cost-benefit ratio. Moreover, its low risk of adhesion formation is important with regard to reproductive prognosis: in the light of this, since the patients are generally young and desire future childbearing, laparoscopy may be the treatment of choice.

Review of 17 cases of ectopic pregnancy at the Vila Central Hospital in Vanuatu

A review of cases of ectopic pregnancy operated upon at Vila Central Hospital during 1992 with an analysis of clinical presenting features and diagnostic factors is presented. Comparison is made between hospital, regional and national figures and possible explanations for the differences are given. Recommendations are made to ensure that ectopic pregnancy is always at the forefront of differential diagnosis in women presenting with abdominal pain.

Current status of surgical and nonsurgical management of ectopic pregnancy

OBJECTIVES

To review the efficacy, safety, costs, and subsequent reproductive outcome of surgical and nonsurgical management of ectopic pregnancy (EP).

DESIGN

Pertinent studies were identified through computer Medline search. The rates of intrauterine pregnancy (IUP) and EP were calculated from the raw data in the original publications so that the denominator would be consistent.

RESULT(S)

The efficacy of laparoscopic treatment of EP is similar to that by laparotomy. The rate of persistent EP after conservative surgery ranges from 3% to 20%. Based on a review of 1,514 patients attempting to conceive after linear salpingostomy, the IUP and recurrent EP rates were 61.4% and 15.4%, respectively, among patients who had laparotomy, and 61% and 15.5%, respectively, among patients who had laparoscopic procedure. Of 3,584 patients who had partial or total salpingectomy, the subsequent IUP rate was 38.1% and the recurrent EP rate was 9.8%. Of 540 patients treated with a single-dose methotrexate, 84% did not require further treatment and, among 215 patients who attempted to conceive, 54% had subsequent IUP and 8% had recurrent EP. The success rate of expectant management was 69.2% in 347 patients reviewed.

CONCLUSION(S)

There is no difference in the reproductive outcome after treatment of EP by laparotomy and by laparoscopy. Salpingostomy is associated with higher subsequent IUP and recurrent EP rates compared with salpingectomy. Methotrexate is a viable alternative to laparoscopic salpingostomy for a selected group of patients.

[Surgical treatment of ectopic pregnancy]

Ectopic pregnancy is a common occurrence. Laparoscopic surgery is the treatment of choice when possible. In this retrospective study we report that the type of surgical treatment of ectopic pregnancy is influenced by the degree of haematoperitoneum, but not by delay by doctor or patient.