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Myers R, Villela V, Chow J, Phelps A, Ghouri M, Alfano M, Yu R, George M. Pediatric Genitourinary Emergencies: What the Radiologist Needs to Know. Semin Roentgenol 2024; 59:332-347. [PMID: 38997185 DOI: 10.1053/j.ro.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Ross Myers
- Medical Imaging of Lehigh Valley, Allentown, PA
| | - Vidal Villela
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Merrimack, NH
| | - Jeanne Chow
- Department of Radiology, Boston Children's Hospital, Boston, MA
| | | | | | | | - Richard Yu
- Department of Urology, Boston Children's Hospital, Boston, MA
| | - Michael George
- Department of Radiology, Boston Children's Hospital, Boston, MA.
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2
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Perysinakis I, Vassalou EE. Non-traumatic lower abdominal pain: ultrasonographic and clinical differential diagnosis. Ultrasonography 2024; 43:151-168. [PMID: 38443147 PMCID: PMC10915120 DOI: 10.14366/usg.23227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/25/2024] [Accepted: 01/27/2024] [Indexed: 03/07/2024] Open
Abstract
Lower abdominal pain is frequently reported and has a diverse differential diagnosis. In cases with atypical presentation and nonspecific findings, further imaging evaluation is required to confirm the clinical suspicion and to distinguish between self-limiting disorders and those requiring immediate intervention. In line with European guidelines, transabdominal ultrasonography is recommended as a first-line imaging modality for clinically suspected acute appendicitis and acute diverticulitis, which respectively represent the predominant causes of right and left lower quadrant abdominal pain. It is similarly the preferred method for evaluating suspected obstetric/gynecologic and genitourinary diseases. Computed tomography is utilized as a secondary option when ultrasonography results are inconclusive. This pictorial essay illustrates the sonographic features of the most common conditions associated with lower abdominal pain and outlines the clinical characteristics of each entity.
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Affiliation(s)
- Iraklis Perysinakis
- Department of Surgical Oncology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Evangelia E. Vassalou
- Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Crete, Greece
- Department of Medical Imaging, General Hospital of Sitia, Sitia, Crete, Greece
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3
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Traisrisilp K, Sethasathien S. Large unruptured tubal pregnancy mimicking abdominal pregnancy. BMJ Case Rep 2023; 16:e256090. [PMID: 37816580 PMCID: PMC10565280 DOI: 10.1136/bcr-2023-256090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Ectopic pregnancy accounts for 1-2% of all pregnancies. Ultrasound is the primary diagnostic tool to locate pregnancy outside the uterus and identify complications such as haemoperitoneum. In inconclusive cases, MRI is an adjunctive imaging modality offering more precise tissue differentiation and helpful to location identification. Presented is an unusual case of tubal pregnancy. The patient in her 30s, who was 14 weeks into her first pregnancy, had a suspected abdominal pregnancy. Both transabdominal ultrasound and an MRI indicated an ectopic pregnancy, likely originating from the right fallopian tube. A successful laparotomy and right salpingectomy were performed without complications. Rarely, as in this case, large unruptured and advanced tubal pregnancies can mimic an abdominal pregnancy, underscoring the importance of disease recognition and familiarity with uncommon image findings. An accurate diagnosis of pregnancy location is crucial for effective case management.
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Affiliation(s)
- Kuntharee Traisrisilp
- Obstetric and Gynecology, Chiang Mai University, Faculty of Medicine, Chiang Mai, Thailand
| | - Sethawat Sethasathien
- Obstetric and Gynecology, Chiang Mai University, Faculty of Medicine, Chiang Mai, Thailand
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4
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Ansari A, Dhok A, Dhawan S, Onkar P, Potdukhe P, Mitra K. Live Cervical Ectopic Pregnancy in a Patient With Previous Cesarean Section: A Case Report With Review of Literature. Cureus 2023; 15:e36940. [PMID: 37139279 PMCID: PMC10151106 DOI: 10.7759/cureus.36940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Live cervical ectopic pregnancy is a rare type of ectopic pregnancy and accounts for <1% of all ectopic pregnancies. Prompt diagnosis and early management with systemic or local administration of methotrexate is the treatment of choice in most cases. If the pregnancy is complicated, it can lead to significant hemorrhage, which may require a hysterectomy to save the life of the patient. We report a case of live cervical ectopic pregnancy in a 26-year-old patient with a history of previous cesarean section and presenting with silent bleeding per vaginum for six hours.
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Le M, Bonde A, Foster B. The "Double Ovary" Sign: A Unique Sonographic Observation in Isolated Fallopian Tube Torsion. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023. [PMID: 36880675 DOI: 10.1002/jum.16208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/03/2023] [Accepted: 02/12/2023] [Indexed: 06/18/2023]
Abstract
Isolated fallopian tube torsion (IFTT) is a rare subset of adnexal torsion. Timely diagnosis of IFTT is essential for preservation of the fallopian tube. However, a pre-operative diagnosis is challenging due to nonspecific symptoms and findings on physical exam. In addition, ultrasound (US) is typically the initial imaging modality in this setting and adnexal torsion may not be considered when normal ovaries are seen. In this small case series, we introduce the "double ovary" sign, a unique observation on US characterized by two adjacent structures: the ovary and the twisted fallopian tube giving rise to an ovary-like, cystic structure. We present three cases in which IFTT was diagnosed preoperatively.
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Affiliation(s)
- Mai Le
- Department of Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Apurva Bonde
- Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Bryan Foster
- Department of Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon, USA
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6
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King SA, Salerno A, Sommerkamp S. Ultrasound in Pregnancy. Emerg Med Clin North Am 2023; 41:337-353. [PMID: 37024168 DOI: 10.1016/j.emc.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
This article reviews the use of ultrasound in pregnancy pertinent to the emergency physician. The techniques for transabdominal and transvaginal studies are detailed including approaches to gestational dating. Diagnosis of ectopic pregnancy is reviewed focusing on the potential pitfalls: reliance on beta-human chorionic gonadotropin, pseudogestational sac, interstitial pregnancy, and heterotopic pregnancy. Techniques for the identification of placental issues and presenting parts during the second and third trimesters are reviewed. Ultrasound is a safe and effective tool for the experienced emergency physician and is integral to providing high-quality care to pregnant women.
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7
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MR of Fallopian Tubes. Magn Reson Imaging Clin N Am 2023; 31:29-41. [DOI: 10.1016/j.mric.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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8
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Wang YN, Zheng LW, Fu LL, Xu Y, Zhang XY. Heterotopic pregnancy after assisted reproductive techniques with favorable outcome of the intrauterine pregnancy: A case report. World J Clin Cases 2023; 11:669-676. [PMID: 36793642 PMCID: PMC9923848 DOI: 10.12998/wjcc.v11.i3.669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/28/2022] [Accepted: 01/09/2023] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Heterotopic pregnancy (HP) is a rare condition in which both ectopic and intrauterine pregnancies occur. HP is uncommon after natural conception but has recently received more attention due to the widespread use of assisted reproductive techniques (ART) such as ovulation promotion therapy.
CASE SUMMARY Here, we describe a case of HP that occurred after ART with concurrent tubal and intrauterine singleton pregnancies. This was treated successfully with surgery to preserve the intrauterine pregnancy, resulting in the birth of a low-weight premature infant. This case report aims to increase awareness of the possibility of HP during routine first-trimester ultrasound examinations, especially in pregnancies resulting from ART and even if multiple intrauterine pregnancies are present.
CONCLUSION This case alerts us to the importance of comprehensive data collection during regular consultations. It is important for us to remind ourselves of the possibility of HP in all patients presenting after ART, especially in women with an established and stable intrauterine pregnancy that complain of constant abdominal discomfort and also in women with an unusually raised human chorionic gonadotropin level compared with simplex intrauterine pregnancy. This will allow symptomatic and timeous treatment of patients with better results.
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Affiliation(s)
- Ya-Nan Wang
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Lian-Wen Zheng
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Lu-Lu Fu
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Ying Xu
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Xue-Ying Zhang
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
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9
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Odedra D, Mellnick VM, Patlas MN. Imaging of Trauma in Pregnancy. Radiol Clin North Am 2023; 61:129-139. [DOI: 10.1016/j.rcl.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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10
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Yun JH, Horrow MM, Goykhman I, Rodgers SK. The Confounding Ultrasound Diagnosis of Ectopic Pregnancy: Lessons From Peer Learning. Ultrasound Q 2022; 38:272-283. [PMID: 35439236 DOI: 10.1097/ruq.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT As the treatment of ectopic pregnancy (EP) has shifted increasingly to medical therapies, the ultrasound (US) diagnosis of EP must necessarily favor specificity over sensitivity. Our review of peer learning cases of EP and early intrauterine pregnancies found several types of pitfalls and problems, which will be described in this essay. These issues include the following: differentiation of tubal EP from a corpus luteum by echogenicity relative to ovarian parenchyma, push technique, and claw sign; how to distinguish interstitial EP from eccentrically located intrauterine pregnancies (angular); use of trophoblastic flow in abnormal intrauterine locations to help identify cesarean scar or cervical implantations; recognition that hemoperitoneum without visualized EP may be due to EP or hemorrhagic cyst; and that distinguishing an abortion in progress from a pregnancy of unknown location may not always be possible and requires clinical follow-up. This essay will also illustrate the consensus terminology that our radiology department has developed in conjunction with our obstetrics and gynecology colleagues to communicate clear diagnoses and reduce the risk of misdiagnosis and adverse outcomes.
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11
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Shazly SA, Radwan AA, Abdo MS, Moustafa HY, Abd-Elkariem AY, Ali SS, Ahmed NB, Hosny EM, Abouzeid MH, Eltaweel NA, Hortu I, Abdelbadie AS, Fahmy MS, Attyia MI, Shawki AA, Said AE, Mohamed YI, Hemdan HN, Hemdan MN, Mohamed NG, Adam RI. Middle-East obgyn graduate education (MOGGE) foundation practice guidelines: diagnostic approach to pregnancy of unknown location: practice guideline no. 03-O-21. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2022. [DOI: 10.1186/s43043-022-00114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pregnancy of unknown location (PUL) is a term used to describe failure of visualization of intrauterine or extrauterine gestational sac in a woman with a positive pregnancy test.
Body of the abstract
Ectopic pregnancy (EP) accounts for 1–2 % of all pregnancies. EP contributes to maternal mortality of a known cause by 4% in developed countries. However, case fatality rate may be 10 times higher in low-resource countries. This may be attributed to delayed diagnosis and lack of resources. PUL is a temporary term that may eventually lead to diagnosis of viable intrauterine pregnancy, pregnancy loss, or more seriously, EP.
Conclusion
This guideline appraises current evidence on assessment of PUL and early diagnosis of EP particularly in low-resource settings.
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12
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Grandelis A, Shaffer R, Tonick S. Uncommon Presentations of Ectopic Pregnancy. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anthony Grandelis
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
| | - Robyn Shaffer
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
| | - Shawna Tonick
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
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Pelvic Pain in Reproductive Age: US Findings. Diagnostics (Basel) 2022; 12:diagnostics12040939. [PMID: 35453987 PMCID: PMC9026765 DOI: 10.3390/diagnostics12040939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/29/2022] Open
Abstract
Pelvic pain in reproductive age often represents a diagnostic challenge due to the variety of potential causes characterized by overlapping clinical symptoms, including gynecological and other disorders (e.g., entero-colic or urological). It is also necessary to determine if there is a possibility of pregnancy to rule out any related complications, such as ectopic pregnancy. Although ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are strongly integrated, the choice of which is the ideal diagnostic tool should be guided both by clinical suspicion (gynecological vs. non-gynecological cause) and by the risk ratio–benefit (ionizing radiation and instrumental costs), too. The didactic objective proposed by this review consists in the diagnosis of the cause and differential of pelvic pain in reproductive age by describing and critically analyzing the US diagnostic clues of the most frequent adnexal, uterine, and vascular causes.
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Campbell LF, Corbo J. Reprint of: Pregnant woman with abdominal pain with abnormal intrauterine pregnancy. Dis Mon 2022; 68:101371. [DOI: 10.1016/j.disamonth.2022.101371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/15/2020] [Accepted: 01/15/2021] [Indexed: 10/18/2022]
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15
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Near fatal interstitial pregnancy: A case report. Am J Emerg Med 2022; 57:235.e5-235.e8. [DOI: 10.1016/j.ajem.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
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16
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Arslan S, Sarıkaya Y, Akata D, Özmen MN, Karçaaltıncaba M, Karaosmanoğlu AD. Imaging findings of spontaneous intraabdominal hemorrhage: neoplastic and non-neoplastic causes. Abdom Radiol (NY) 2022; 47:1473-1502. [PMID: 35230499 DOI: 10.1007/s00261-022-03462-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 02/07/2023]
Abstract
Contrary to traumatic and iatrogenic intraabdominal hemorrhages, spontaneous intraabdominal hemorrhage is a challenging clinical situation. A variety of neoplastic and non-neoplastic conditions may cause spontaneous intraabdominal bleeding. Imaging findings vary depending on the source of bleeding and the underlying cause. In this article, we aim to increase the awareness of imagers to the most common causes of spontaneous intraabdominal hemorrhage by using representative cases.
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Affiliation(s)
- Sevtap Arslan
- Department of Radiology, Suhut State Hospital, 03800, Afyon, Turkey
| | - Yasin Sarıkaya
- Department of Radiology, Afyonkarahisar Health Sciences University, 03217, Afyon, Turkey
| | - Deniz Akata
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06230, Ankara, Turkey
| | - Mustafa Nasuh Özmen
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06230, Ankara, Turkey
| | - Muşturay Karçaaltıncaba
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06230, Ankara, Turkey
| | - Ali Devrim Karaosmanoğlu
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06230, Ankara, Turkey.
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Ku CW, Ong I, Chan JKY, Ee TX. Abdominal heterotopic pregnancy post-IVF double embryo transfer. BMJ Case Rep 2022; 15:15/2/e246649. [PMID: 35131787 PMCID: PMC8823037 DOI: 10.1136/bcr-2021-246649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Uterosacral ligament (USL) is an uncommon site of implantation for abdominal ectopic pregnancies. This is the first case of USL heterotopic pregnancy post invitro fertilisation (IVF). The patient presented 6 weeks after a double embryo transfer with acute onset abdominal pain and was diagnosed with a suspected live tubal ectopic pregnancy with a viable intrauterine pregnancy on ultrasound. A diagnostic laparoscopy revealed an ectopic pregnancy implanted on the left USL which was resected and confirmed on histology. The patient was discharged well on postoperative day 2 with a viable intrauterine pregnancy. This case highlights the importance of considering non-tubal heterotopic pregnancies in the context of risk factors including IVF with double embryo transfer presenting with abdominal pain.
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Affiliation(s)
- Chee Wai Ku
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Isabella Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jerry Kok Yen Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tat Xin Ee
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
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18
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Loukopoulos T, Zikopoulos A, Mastora E, Galani A, Stavros S, Kolibianakis E. Multidose methotrexate treatment of cornual pregnancy after in vitro fertilization: Two case reports. Case Rep Womens Health 2022; 33:e00376. [PMID: 34993055 PMCID: PMC8713054 DOI: 10.1016/j.crwh.2021.e00376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 11/28/2022] Open
Abstract
Background An ectopic pregnancy, when the gestational sac is implanted outside of the uterine cavity, can be life-threatening. A cornual pregnancy is the most dangerous type of ectopic pregnancy since it can be misdiagnosed easily and has high mortality rate. It is diagnosed when the implantation site is at the junction between the fallopian tube and the uterus. For a successful outcome, early diagnosis and management are critical. The traditional management is surgical, involving cornual resection or hysterectomy, which, however, affects fertility. Thus, conservative management involving administration of methotrexate should always be considered. Case presentation The article describes to two women in their early forties with no previous children (G1, P0) and diagnosed with a cornual pregnancy at 7 and 8 weeks of gestation following in vitro fertilization. Given their hemodynamic stability and their desire to conserve fertility they were treated conservatively. The two patients had similar ultrasound findings and blood results. The main difference was the presence of an embryonic heart beat in one case. Successful management was accomplished with multidose methotrexate and leucovorin during hospitalization for 8 days and close monitoring for the next 30 days as outpatients. In addition, the second woman was given a transvaginal injection of potassium chloride (KCL) to stop embryonic cardiac activity. Conclusion Conservative management of cornual pregnancies applying multidose therapy of methotrexate and leucovorin is a safe treatment when patients are asymptomatic and preserves fertility. Cornual pregnancy is the most dangerous type of ectopic pregnancy. Conservative treatment using multiple doses of methotrexate is safe and effective. When fetal cardiac activity is present KCL injection should be used. If the woman becomes hemodynamically unstable an operation is the only solution. With conservative management female fertility remains unaffected.
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Affiliation(s)
- T Loukopoulos
- University Hospital of Ioannina, Department of Obstetrics and Gynecology, Ioannina, Greece
| | - A Zikopoulos
- Obstetrics and Gynecology Royal Cornwall Hospital, Cornwall, UK
| | - E Mastora
- University Hospital of Ioannina, Department of Obstetrics and Gynecology, Ioannina, Greece
| | - A Galani
- University Hospital of Ioannina, Department of Obstetrics and Gynecology, Ioannina, Greece
| | - S Stavros
- 1 Department of Obstetrics and Gynecology, University of Athens, General Hospital "Alexandra", Athens, Greece
| | - E Kolibianakis
- 3 Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Ectopic pregnancy: a resident's guide to imaging findings and diagnostic pitfalls. Emerg Radiol 2021; 29:161-172. [PMID: 34618256 DOI: 10.1007/s10140-021-01974-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
Ectopic pregnancy (EP) is a term used to describe any pregnancy which does not implant into the uterine cavity. There are several types of EPs: tubal, interstitial, ovarian, abdominal, heterotopic, cervical, and cesarean scar. Ectopic pregnancies can acutely rupture and are the number one cause of maternal death in the first trimester of pregnancy. Therefore, prompt recognition and accurate localization have significant clinical implications on patient outcome. Unfortunately, EPs have many mimickers, which can make the diagnosis challenging in certain cases. In this review, we aim to describe and illustrate sonographic findings of each type of EP, as well as present mimickers and various imaging pitfalls. We will clarify how to avoid potential misdiagnoses that could adversely affect patient outcomes. Lastly, we will briefly address management of each type of EP and discuss potential complications.
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20
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Diagnostic Accuracy of Preoperative Conventional MRI for Patients With Ectopic Pregnancy. Int Surg 2021. [DOI: 10.9738/intsurg-d-17-00117.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
To assess the utility of preoperative magnetic resonance imaging (MRI) in the diagnosis of tubal pregnancy.
Summary of background data
Most cases of ectopic pregnancy are tubal pregnancies. Preoperative accurate diagnosis including the location of the tubal pregnancy is important.
Method
We performed a retrospective single-center cohort study evaluating patients who underwent surgery for ectopic pregnancy from April 2004 to March 2016 and who underwent preoperative MRI. Sixty patients were enrolled in the study. Chorion confirmed at the tubal pregnancy site detected by MRI was defined as a correct diagnosis.
Results
Mean estimated gestational age at the time of MRI according to the last menstrual period was 7 weeks (median: 5 weeks; range: 3–10 weeks). Ectopic pregnancy was diagnosed by MRI in 57 cases, and all cases were either left or right tubal pregnancy. In 52 cases, the actual position matched the MRI findings. In 5 cases, the location of tubal ectopic pregnancy was different from that diagnosed by MRI, or no tubal pregnancy was observed intraoperatively. In 2 cases, no ectopic pregnancy site was observed on MRI, but tubal pregnancy was confirmed by surgery. In one case, an ectopic pregnancy site was not found, and the tube showed normal findings on MRI. The sensitivity of MRI diagnosis was 96.2%, specificity was 16.7%, positive predictive value was 91.1%, and negative predictive value was 33.3%.
Conclusion
In cases of ectopic pregnancy treated surgically, the sensitivity of MRI diagnosis, including identification of the location of ectopic pregnancy, is high.
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21
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Imaging evaluation of uterine perforation and rupture. Abdom Radiol (NY) 2021; 46:4946-4966. [PMID: 34129055 DOI: 10.1007/s00261-021-03171-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/05/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022]
Abstract
Uterine perforation and rupture, denoting iatrogenic and non-iatrogenic uterine wall injury, respectively, are associated with substantial morbidity,and at times mortality. Diverse conditions can result in injury to both the gravid and the non-gravid uterus, and imaging plays a central role in diagnosis of such suspected cases. Ultrasound (US) is the initial imaging modality of choice, depicting the secondary signs associated with uterine wall injury and occasionally revealing the site of perforation. Computed tomography can be selectively used to complement US findings, to provide a more comprehensive picture, and to investigate complications beyond the reach of US, such as bowel injury. In certain scenarios, magnetic resonance imaging can be an important problem-solving tool as well. Finally, catheter angiography is a valuable tool with both diagnostic and therapeutic capability, with potential for fertility preservation. In this manuscript, we will highlight the clinical and imaging approach to uterine perforation and rupture, while emphasizing the value of various imaging modalities in this context. In addition, we will review the multi-modality imaging features of uterine perforation and rupture and will address the role of the radiologist as a crucial member of the management team. Finally, a summary diagrammatic depiction of imaging approach to patients presenting with uterine perforation or rupture is provided.
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22
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Díaz-Narváez MC, Enriquez-Enriquez EC. Embarazo heterotópico de ubicación tubárica. Reporte de caso. CASE REPORTS 2021. [DOI: 10.15446/cr.v7n2.86507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. El embarazo heterotópico se considera una patología de interés debido a que, aunque su incidencia es baja, su tasa de mortalidad es elevada; además, esta es una entidad que representa un reto diagnostico por sus diversas presentaciones clínicas.
Presentación del caso. Mujer de 32 años, mestiza, procedente de Pasto (Colombia) y en estado de embarazo, quien asistió al servicio de urgencias de una institución de tercer nivel de atención por un dolor abdominal difuso asociado a sangrado vaginal. Teniendo en cuenta los hallazgos imagenológicos (ecografía) y los niveles de gonadotropina encontrados, la paciente fue diagnosticada con embarazo heterotópico de ubicación tubárica derecha que requirió tratamiento quirúrgico por laparotomía. A los 8 días del procedimiento la paciente asistió a control y mediante ecografía se evidenció continuidad de embarazo intrauterino.
Conclusiones. El pilar fundamental para el diagnóstico del embarazo heterotópico es la sospecha clínica, pero es necesario confirmarlo mediante ayudas diagnosticas como la ecografía y a través de la medición de los niveles de gonadotropina coriónica humana. Este evento se debe sospechar en pacientes con cuadro de dolor abdominal a pesar de que no tengan factores de riesgo para presentarlo. La elección de tratamiento (médico o quirúrgico) depende de la condición clínica y hemodinámica de cada paciente y de la ubicación y el tamaño del embarazo ectópico.
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Abdelmonem AH, Sayed G, Abugazia AE, Kohla S, Youssef R. Heterotopic pregnancy after a spontaneous conception a case report with a review of clinical, laboratory and imaging findings. Clin Case Rep 2021; 9:e04649. [PMID: 34430013 PMCID: PMC8365543 DOI: 10.1002/ccr3.4649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/24/2021] [Accepted: 07/12/2021] [Indexed: 11/10/2022] Open
Abstract
Heterotopic pregnancy (HP) describes the simultaneous presence of two pregnancies at different implantation sites. Usually, one pregnancy is intrauterine and the other one is ectopic. The incidence of HP after assisted reproductive technologies reaches 1:3900, but is very rare after a spontaneous pregnancy, with a reported incidence of 1 to 30,000 pregnancies. Due to its rarity, complex clinical picture, and laboratory findings, it is challenging to diagnose HP. We present a case of spontaneous HP diagnosed in the first trimester by ultrasound (US) and magnetic resonance imaging (MRI) and subsequently managed successfully. We present an analysis of the clinical and laboratory findings as well as imaging, including MRI that we used to diagnose the condition. Additionally, we performed a literature review. CONCLUSIONS HP is a very rare condition frequently faced in obstetrics, gynecology, and emergency departments that requires a high index of clinical suspicion. US remains the imaging modality of choice in diagnosing a HP, however, in some cases, an MRI with a reported safety in the first trimester, can be used to provide additional information over US.
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Affiliation(s)
- Ahmed H. Abdelmonem
- Department of RadiologyHamad General HospitalDohaQatar
- Weill Cornell Medicine QatarDohaQatar
| | - Gamal Sayed
- Weill Cornell Medicine QatarDohaQatar
- Department of Obstetrics & GynecologyWomen’s Wellness and Research CenterDohaQatar
- Clinical DepartmentCollege of MedicineQU HealthQatar UniversityDohaQatar
- University of DundeeDundeeUK
| | | | - Samah Kohla
- Weill Cornell Medicine QatarDohaQatar
- Department of Laboratory Medicine and PathologyHematology DivisionHamad Medical CorporationDohaQatar
| | - Reda Youssef
- Weill Cornell Medicine QatarDohaQatar
- Department of RadiologyWomen’s Wellness and Research CenterDohaQatar
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Magnetic Resonance Imaging Evaluation of Ectopic Pregnancy: A Value-Added Review. J Comput Assist Tomogr 2021; 45:374-382. [PMID: 33797439 DOI: 10.1097/rct.0000000000001148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Ectopic pregnancy (EP) is a known cause of maternal mortality and may be misdiagnosed in up to 50% of pregnant female individuals (Ann Emerg Med. 1996;28(1):10-17). Magnetic resonance imaging, with its superior soft tissue resolution, is a valuable alternative diagnostic modality to diagnose EP when transvaginal ultrasound results are inconclusive. Although an extrauterine gestational sac is the most specific finding, there are other key MRI findings that can aid in diagnosing EP. As availability of MRI access in the emergency department setting increases across the nation, its utility in women with a positive pregnancy test has also increased. Specific MRI findings that are diagnostic of EP include absence of intrauterine pregnancy, adnexal mass separate from the ovary, and hemoperitoneum. In addition, intrauterine ectopic locations, especially intramural, cornual, and cervical pregnancies, can be diagnosed with increased accuracy with the help of MRI. Magnetic resonance imaging is also useful in excluding potential mimics of EP, including adnexal cysts, ovarian neoplasms, and fibroids. In summary, providing an accurate diagnosis and determining the precise location of an EP, which is supported by the use of MRI, is imperative for guiding a patient's treatment to prevent a potentially fatal outcome.
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Diagnosis and Management of Ectopic Pregnancy: A Comparative Review of Major National Guidelines. Obstet Gynecol Surv 2021; 75:611-623. [PMID: 33111962 DOI: 10.1097/ogx.0000000000000832] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Ectopic pregnancies (EPs) represent a severe early pregnancy complication that is associated with increased risks of maternal morbidity and mortality. Over the years, there has been a significant reduction in the mortality from this complication by improving the diagnostic tools and the treatment options. Objective The aim of this study was to review and compare the recommendations from published guidelines on this potentially fatal condition. Evidence Acquisition A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence on EP was carried out. Results All the guidelines point out the crucial role of sonography in the prompt diagnosis of EP and describe similar sonographic findings. There is a consensus on the indications and contraindications to the use of methotrexate, the post-treatment surveillance, and the criteria of expectant management. The indications for a surgical approach are not well established, although the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence agree that a laparoscopy is preferred to laparotomy for hemodynamically stable patients. The latter is considered a better option only in emergency conditions. However, there is controversy in the recommended methotrexate protocols and the evaluation of β-human chorionic gonadotrophin and progesterone levels. Conclusion It is of paramount importance to build consistent international protocols, so as to help clinicians all over the world diagnose EPs in the most timely and accurate way and subsequently treat them effectively as a nonurgent medical condition, with the intention to lower the mortality and morbidity rate.
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Pinto Ribeiro PC, Amann N, Alba Alejandre I, Kost B, Mahner S, Kaltofen T. Persistent increase of β-hCG level after salpingectomy in tubal pregnancy: Good or bad news? Clin Case Rep 2021; 9:2369-2372. [PMID: 33936697 PMCID: PMC8077415 DOI: 10.1002/ccr3.4039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/17/2022] Open
Abstract
Heterotopic pregnancy is a rare event in natural conception (1:30000). We describe a case of a 36-year-old nulliparous. She presented to our department in the 4 + 6 gestational week with two simultaneous pregnancies intrauterine and extrauterine. Here, we compare treatment options and ultrasound findings to help examiners avoid inadequate therapeutic approaches.
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Affiliation(s)
| | - Niklas Amann
- Department of Obstetrics and GynecologyLMU MunichMunichGermany
| | | | - Bernd Kost
- Department of Obstetrics and GynecologyLMU MunichMunichGermany
| | - Sven Mahner
- Department of Obstetrics and GynecologyLMU MunichMunichGermany
| | - Till Kaltofen
- Department of Obstetrics and GynecologyLMU MunichMunichGermany
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The many faces of ectopic pregnancies: demystifying the common and less common entities. Abdom Radiol (NY) 2021; 46:1104-1114. [PMID: 32889610 DOI: 10.1007/s00261-020-02681-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022]
Abstract
Ectopic pregnancy is a major cause of 1st trimester pregnancy deaths. It occurs in various locations in the abdominopelvic cavity. Ultrasonography is a first-line, rapid, and noninvasive modality for ectopic pregnancy evaluation. MRI can help clarify equivocal cases. When in doubt about the location, one should give an intrauterine pregnancy the benefit of the doubt with close ultrasound and hCG follow-up. Here, we will review the imaging findings and mimickers of ectopic pregnancies.
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Kong M, Paramesparan K, Keshvala C, Shah A. Acute abdomen or life-threatening heterotopic pregnancy with tubal rupture: where does imaging play a role? BMJ Case Rep 2020; 13:13/12/e239178. [PMID: 33361138 PMCID: PMC7759969 DOI: 10.1136/bcr-2020-239178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Heterotopic pregnancy (HP) is a rare, potentially life-threatening complication of an intrauterine pregnancy with a simultaneous ectopic pregnancy. There is a higher incidence with assisted reproduction techniques (ART) and radiology can be pivotal in its diagnosis. A 28-year-old woman underwent ART and at 7 weeks' gestation presented with acute right iliac fossa pain. Transvaginal ultrasound (US) imaging confirmed a viable intrauterine pregnancy. The patients' pain persisted however, and transabdominal US demonstrated a complex, heterogeneous right adnexal mass. Subsequent magnetic resonance imaging (MRI) confirmed an HP with a ruptured ectopic and haemoperitoneum. Emergency laparoscopic surgery and right salpingo-oopherectomy were performed without complication. We highlight the importance of considering HP as a diagnosis in the acute gravid abdomen, especially when initial investigations have confirmed a viable intrauterine pregnancy. Furthermore, this case highlights MRI as a useful modality in complex cases due to its high soft tissue contrast resolution using non-ionising radiation.
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Affiliation(s)
- Mark Kong
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Chhaya Keshvala
- Radiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Amit Shah
- Radiology, University Hospitals of Leicester NHS Trust, Leicester, UK
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Benedict MA, Adefuye AO. A classic case suggestive of an unruptured ectopic pregnancy with unexpected finding of a unilateral dermoid cyst intraoperatively: A case report. S Afr Fam Pract (2004) 2020; 62:e1-e5. [PMID: 33314946 PMCID: PMC8378139 DOI: 10.4102/safp.v62i1.5164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/19/2020] [Accepted: 09/20/2020] [Indexed: 11/28/2022] Open
Abstract
Acute lower abdominal pain or pelvic pain is a common presenting complaint in women of reproductive age, which can be accounted for by numerous aetiologies. The presentation of lower abdominal pain with associated findings of an adnexal mass on transvaginal ultrasonography and positive beta-human chorionic gonadotropin (β-hCG) (serum and urine) in a sexually active woman of reproductive age is an ectopic pregnancy until proven otherwise. Here, we present a classic case suggestive of an unruptured ectopic pregnancy, with an unexpected finding of a unilateral dermoid cyst intraoperatively in a 33-year-old woman. Findings presented herein suggest that practitioners in our local setting should evaluate patients carefully, and consider neoplasms as a possible source of β-hCG production in sexually active women of reproductive age who present with subacute lower abdominal pain, identified adnexal mass on ultrasonography and positive serum or urine β-hCG readings.
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Affiliation(s)
- Matthew A Benedict
- Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein.
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30
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Yip SL, Siraj SHM, Chan JKY. Caution with bilateral salpingectomy and consideration of tubal stump ectopic in IVF. BMJ Case Rep 2020; 13:13/11/e235893. [PMID: 33257356 DOI: 10.1136/bcr-2020-235893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a 35-year-old female patient with a history of bilateral salpingectomy from ectopic pregnancies presenting with a positive serum beta-human chorionic gonadotropin (bhCG) result following in vitro fertilisation (IVF) treatment. Apart from per vaginal spotting, she remained asymptomatic. Initial ultrasound showed an empty uterus with a cystic mass on the right side of the uterus. Serum beta-hCG was trended. A follow-up pelvic ultrasound 1 week later showed a live pregnancy in the right adnexa. A diagnostic laparoscopy was performed, which revealed an unruptured right stump ectopic pregnancy that was successfully removed. As a stump ectopic pregnancy can be a potentially life-threatening occurrence, we emphasise caution with salpingectomy and the consideration of tubal stump ectopic pregnancies following IVF treatment.
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Affiliation(s)
- Swee Lin Yip
- Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | | | - Jerry Kok Yen Chan
- Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
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31
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Elhadidi A, Alhariri A, Hosny Garib M, Mansour A, Almutiri B. Ruptured Heterotopic Pregnancy: A Rare Encounter in Acute Surgical Care Settings. Cureus 2020; 12:e11782. [PMID: 33409029 PMCID: PMC7779178 DOI: 10.7759/cureus.11782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Heterotopic pregnancy is a rare, life-threatening clinical entity with an overall incidence of about 1:30,000 in spontaneous natural conception cases, especially in cases of delayed diagnosis or conflicting clinical features. Here, we present an unusual case of heterotopic pregnancy in a 22-year-old multigravida presented to the emergency department (ED) with a clinical picture of the acute abdomen following recent abdominal trauma. Abdominal ultrasound revealed hemoperitoneum and a single viable intrauterine pregnancy at seven weeks' gestation. Following surgical exploration, the patient underwent removal of the ectopic pregnancy tissue with right salpingectomy. Since the presence of a conflicting history or equivocal physical signs and symptoms makes it difficult to diagnose heterotopic pregnancy, ED physicians and surgeons must consider the diagnosis even when dealing with viable intrauterine pregnancies. Besides, acute abdominal pain associated with shock should be regarded as suggestive of heterotopic pregnancy. Thus, prompt evaluation and a high index of suspicion are of paramount importance to prevent unwanted sequelae.
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Abstract
OBJECTIVE To evaluate outpatient opioid dispensing and the incidence of persistent opioid use after ectopic pregnancy. METHODS This cohort study used U.S. employer-based claims data to identify opioid-naïve individuals experiencing ectopic pregnancy from November 1, 2008, to September 30, 2015. Treatment was categorized as surgical, medical (using methotrexate), or unknown. New opioid prescriptions were defined as prescriptions filled from 1 week before to 1 week after an ectopic pregnancy treatment. For those who filled a new opioid prescription, we calculated the incidence and risk factors for persistent opioid use, defined as having filled at least one opioid prescription both from 8 to 90 days after treatment and from 91 to 365 days after treatment. RESULTS Of the 15,338 individuals in our study, 7,047 (45.9%, 95% CI 45.2-46.7%) filled an opioid prescription at the time of treatment, of whom 4.1% (95% CI 3.6-4.6%) developed persistent opioid use. The risk of persistent opioid use was lower among those who had surgical compared with medical treatment (3.7% and 6.8%, respectively; relative risk [RR] 0.54, 95% CI 0.38-0.77). Variables most strongly associated with persistent opioid use were a history of benzodiazepine use (RR 1.99; 95% CI 1.43-2.78; adjusted relative risk [aRR] 1.57, 95% CI 1.11-2.22), antidepressant use (RR 1.91, 95% CI 1.45-2.53; aRR 1.53, 95% CI 1.08-2.18), and a pre-existing pain disorder (RR 1.58, 95% CI 1.26-1.99; aRR 1.47, 95% CI 1.16-1.85) in the year before treatment. CONCLUSION New opioid use is common after an ectopic pregnancy; approximately 4% of those with new opioid use develop persistent opioid use, with the rate higher in those treated medically. New pain-management guidelines need to be developed to prevent persistent opioid use after ectopic pregnancy.
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Sharma P, Hegde R, Kulkarni A, Soin P, Kochar P, Rotem E. Imaging right lower quadrant pain: Not always appendicitis. Clin Imaging 2020; 63:65-82. [PMID: 32163846 DOI: 10.1016/j.clinimag.2020.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/22/2020] [Accepted: 02/24/2020] [Indexed: 12/12/2022]
Abstract
Although acute appendicitis (AA) is one of the commonest causes of right lower quadrant abdominal pain (RLQP), there are numerous other conditions in the abdomen and pelvis that can simulate the clinical presentation of AA for which imaging is essential in detection. We discuss the approach to evaluation of patients presenting with acute onset RLQP and the choice of various imaging modalities that can be utilized. Although CT remains the workhorse in evaluation, US and MRI, given lack of radiation, play an important ancillary role, particularly in the pediatric and pregnant patients. We present a spectrum of conditions presenting with RLQP which we have classified systematically ranging from conditions affecting the bowel, mesentery/omentum/peritoneum, vasculature, urinary and reproductive systems to give the reader a checklist of conditions to consider when evaluating a case of RLQP.
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Affiliation(s)
- Pranav Sharma
- Department of Radiology, Yale New Haven Health - Bridgeport Hospital, Bridgeport, CT, United States of America
| | - Rahul Hegde
- Department of Radiology, Yale New Haven Health - Bridgeport Hospital, Bridgeport, CT, United States of America.
| | - Ashwini Kulkarni
- Department of Radiology, University of Massachusetts, Worcester, MA, United States of America
| | - Priti Soin
- Department of Pathology, Penn State College of Medicine, Hershey, PA, United States of America
| | - Puneet Kochar
- Department of Radiology, Yale New Haven Health - Bridgeport Hospital, Bridgeport, CT, United States of America
| | - Eran Rotem
- Department of Radiology, Yale New Haven Health - Bridgeport Hospital, Bridgeport, CT, United States of America
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Refining Angular Pregnancy Diagnosis in the First Trimester: A Case Series of Expectant Management. Obstet Gynecol 2020; 135:175-184. [PMID: 31809430 DOI: 10.1097/aog.0000000000003595] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the natural history and outcomes of a large cohort of expectantly managed angular pregnancies diagnosed in the first trimester by specific ultrasound criteria. METHODS We conducted a prospective case series of women with prenatally diagnosed angular pregnancy at a single academic tertiary care center from March 2017 to February 2019. Participants were identified at first-trimester ultrasound scan using specifically proposed diagnostic criteria for angular pregnancy and followed prospectively. Maternal and fetal data were gathered from the medical record. RESULTS Forty-two cases of angular pregnancy were identified at first-trimester ultrasound scan. At presentation, 33 patients (79%) were asymptomatic, eight (19%) had vaginal bleeding, and two (5%) had pain. The mean gestational age at diagnosis was 7.4±1.0 weeks; the mean myometrial thickness was 5.1±1.6 mm (95% CI 4.6-5.6). At initial follow-up about 2 weeks later, 23 patients (55%) had ultrasound scans that normalized, 13 (31%) cases persisted as angular pregnancies, and six (14%) resulted in early pregnancy loss. After each gestation had been followed until completion, 33 (80%) pregnancies resulted in live birth and eight (20%) in early pregnancy loss. One patient was lost to follow-up. Of the 33 live births, 24 (73%) were vaginal deliveries, nine (27%) were cesarean deliveries, 27 (82%) were term deliveries, and six (18%) were preterm deliveries. There were no cases of uterine rupture, maternal death, abnormal placentation, or hysterectomy. CONCLUSIONS In 42 cases of angular pregnancy diagnosed by first-trimester ultrasound examination, outcomes were largely positive, with an 80% live-birth rate and a 20% early pregnancy loss rate. Early diagnosis of angular pregnancy using the described criteria may represent an entity that more closely resembles a normal, noneccentric intrauterine pregnancy rather than an ectopic pregnancy. Therefore, most cases can be closely observed and efforts made to expectantly manage pregnancies while awaiting viability.
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Tonolini M, Foti PV, Costanzo V, Mammino L, Palmucci S, Cianci A, Ettorre GC, Basile A. Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part I: corpus luteum and haemorrhagic ovarian cysts, genital causes of haemoperitoneum and adnexal torsion. Insights Imaging 2019; 10:119. [PMID: 31853900 PMCID: PMC6920287 DOI: 10.1186/s13244-019-0808-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 10/18/2019] [Indexed: 01/06/2023] Open
Abstract
Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Although ultrasound is the ideal non-invasive first-line technique, nowadays multidetector computed tomography (CT) is extensively used in the ED, particularly when a non-gynaecologic disorder is suspected and differential diagnosis from gastrointestinal and urologic diseases is needed. As a result, CT often provides the first diagnosis of female genital emergencies. If clinical conditions and scanner availability permit, magnetic resonance imaging (MRI) is superior to CT for further characterisation of gynaecologic abnormalities, due to the excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation. The purpose of this pictorial review is to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their cross-sectional imaging appearances. The present first section will review the CT and MRI findings of corpus luteum and haemorrhagic ovarian cysts, gynaecologic haemoperitoneum (from either ruptured corpus luteum or ectopic pregnancy) and adnexal torsion, with an emphasis on differential diagnosis. Additionally, comprehensive and time-efficient MRI acquisition protocols are provided.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Pietro Valerio Foti
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Valeria Costanzo
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Luca Mammino
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Stefano Palmucci
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical-Surgical Specialties, Institute of Obstetrics and Ginecology, University of Catania, Catania, Italy
| | - Giovanni Carlo Ettorre
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
| | - Antonio Basile
- Department of Medical Surgical Sciences and Advanced Technologies, Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, 95123, Catania, Italy
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Pseudoembryo associated with pseudogestational sac: A novel sonographic finding in ectopic pregnancy. Eur J Radiol Open 2019; 6:281-283. [PMID: 31440526 PMCID: PMC6700323 DOI: 10.1016/j.ejro.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 11/23/2022] Open
Abstract
In this case report, we present a case of a hitherto undescribed "pseudoembryo" appearance in a fluid-filled endometrial cavity in ectopic pregnancy. Knowledge of this sonographic finding is clinically important, since the presence of a "pseudoembryo" could lead to the misidentification of a pseudogestational sac as an intrauterine pregnancy in the setting of ectopic pregnancy. This paper discuss reviews the pseudogestational sac and imaging findings which differentiate it from a true intrauterine gestation.
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Hirshberg B, Rheinboldt M. Multimodality imaging of acute locoregional and systemic complications in the setting of assisted reproduction. Emerg Radiol 2019; 26:205-219. [PMID: 30631995 DOI: 10.1007/s10140-018-01665-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/13/2018] [Indexed: 02/02/2023]
Abstract
Over the past 40 years since the first in vitro fertilization was performed, both the role of assisted reproductive technology (ART) in establishing viable pregnancy as well as the available treatment options have expanded enormously. Annually in the USA, nearly 2% of pregnancies now employ some form of ART assistance, with in vitro fertilization (IVF) being the most commonly utilized methodology. Both maternal and fetal risks are elevated in ART pregnancies, the latter including adverse outcome due to both increased gestational number as well as advanced maternal age. Maternal risks may be divided into locoregional and systemic complications. Adverse pelvic complications include those relating to gamete harvesting and transfer, ovarian hyperstimulation, the sequela of ectopic and heterotopic pregnancies, as well as ovarian torsion, all of which are elevated in the ART cohort. Ovarian hyperstimulation syndrome is the most commonly encountered complication, with both systemic and pelvic features relating to increased vascular permeability, hemoconcentration, and ascites. While life-threatening cases are relatively rare, moderate and severe manifestations may occur in up to 10% of ART cycles and, as such, are a not infrequent cause for ER visitation. Familiarity with the clinical and imaging manifestations of ART complications as well as their prognostic implications will facilitate a timely diagnosis and assist the interpreting radiologist in best expediting appropriate clinical care. In this article, we will briefly discuss the current methodology of ART then present an imaging-based multimodality review of the potentially encountered adverse maternal sequela, highlighting key diagnostic features and differential considerations as well as potential prognostic implications.
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Magnetic resonance imaging of common, uncommon, and rare implantation sites in ectopic pregnancy. Abdom Radiol (NY) 2018; 43:3425-3435. [PMID: 29713741 DOI: 10.1007/s00261-018-1604-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To review the MRI appearances of tubal and non-tubal implantation sites in ectopic pregnancy. CONCLUSION Transvaginal ultrasound is the primary imaging modality in ectopic pregnancy and MRI is used as a problem-solving tool in selected indications as detailed in the article. MRI features of tubal, interstitial, cervical, cesarean scar, cornual, ovarian, abdominal, and heterotopic pregnancies are provided to familiarize the radiologists with their appearances thereby assisting them in making early and accurate diagnosis.
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Gao T, Sun M, Yao L, Jiang W. False diagnosis of and needless therapy for presumed gestational trophoblastic disease in women with an unusual site of residual pregnancy. J Int Med Res 2018; 47:673-681. [PMID: 30409101 PMCID: PMC6381454 DOI: 10.1177/0300060518807600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective This study aimed to determine the diagnostic value of magnetic resonance imaging (MRI), hysteroscopy, and laparoscopy to avoid unnecessary treatment when patients present with clinical manifestations that are close to those of gestational trophoblastic neoplasia (GTN). Methods Three patients who were falsely diagnosed with presumed GTN and received needless chemotherapy in our hospital from July 2011 to March 2012 were studied. We also reviewed data of patients with similar clinical features who were diagnosed as having residual pregnancy in recent years. Clinical manifestations were evaluated. Results All three patients had persistently high serum β-human chorionic gonadotrophin levels and a mass with abundant blood supply in the uterus after termination of pregnancy. The patients were diagnosed with GTN and underwent chemotherapy. They responded poorly to chemotherapy and underwent surgery. The pathological diagnosis in all patients was residual pregnancy. In recent years, no patients were misdiagnosed because pelvic MRI, hysteroscopy, or laparoscopy was used when residual pregnancy could not be excluded. Conclusion Gynecologists should diagnose carefully when patients present with clinical manifestations that are close to those of GTN to avoid unnecessary treatment. MRI, hysteroscopy, and laparoscopy could be important examinations for excluding residual pregnancy.
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Affiliation(s)
- Tong Gao
- 1 Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,2 Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Mingming Sun
- 1 Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,2 Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Liangqing Yao
- 1 Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,2 Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Wei Jiang
- 1 Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,2 Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
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Bahouth SM, Wong VK, Kampalath RV, Lin J, Mankowski-Gettle L. US Findings of First-Trimester Pregnancy RadioGraphics Fundamentals | Online Presentation. Radiographics 2018; 38:2193-2194. [DOI: 10.1148/rg.2018180065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sara M. Bahouth
- From the Department of Radiology, Baylor College of Medicine, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (S.M.B., V.K.W., R.V.K., J.L.); and Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (L.M.G.)
| | - Vincenzo K. Wong
- From the Department of Radiology, Baylor College of Medicine, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (S.M.B., V.K.W., R.V.K., J.L.); and Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (L.M.G.)
| | - Rony V. Kampalath
- From the Department of Radiology, Baylor College of Medicine, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (S.M.B., V.K.W., R.V.K., J.L.); and Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (L.M.G.)
| | - Jay Lin
- From the Department of Radiology, Baylor College of Medicine, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (S.M.B., V.K.W., R.V.K., J.L.); and Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (L.M.G.)
| | - Lori Mankowski-Gettle
- From the Department of Radiology, Baylor College of Medicine, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (S.M.B., V.K.W., R.V.K., J.L.); and Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (L.M.G.)
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Errázuriz J, Racca A, Schutyser V, Frederix B, Blockeel C. Cornual twin pregnancy following IVF/ICSI treatment. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:287-288. [PMID: 29876991 DOI: 10.1002/uog.19109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 05/25/2018] [Accepted: 05/27/2018] [Indexed: 06/08/2023]
Affiliation(s)
- J Errázuriz
- Universitair Ziekenhuis Brussel, Centre for Reproductive Medicine, Brussels, Belgium
- Reproductive Medicine Unit, Clínica Alemana, Santiago, Chile
| | - A Racca
- Universitair Ziekenhuis Brussel, Centre for Reproductive Medicine, Brussels, Belgium
- Academic Unit of Obstetrics and Gynecology, IRCCS AOU San Martino - IST, University of Genoa, Genova, Italy
| | - V Schutyser
- Universitair Ziekenhuis Brussel, Centre for Reproductive Medicine, Brussels, Belgium
| | - B Frederix
- Universitair Ziekenhuis Brussel, Centre for Reproductive Medicine, Brussels, Belgium
| | - C Blockeel
- Universitair Ziekenhuis Brussel, Centre for Reproductive Medicine, Brussels, Belgium
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Brown DL, Packard A, Maturen KE, Deshmukh SP, Dudiak KM, Henrichsen TL, Meyer BJ, Poder L, Sadowski EA, Shipp TD, Simpson L, Weber TM, Zelop CM, Glanc P. ACR Appropriateness Criteria ® First Trimester Vaginal Bleeding. J Am Coll Radiol 2018; 15:S69-S77. [DOI: 10.1016/j.jacr.2018.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 12/27/2022]
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Jiang Y, Chen J, Zhou H, Zheng M, Han K, Ling J, Zhu X, Tang X, Li R, Hong Y. Management and obstetric outcomes of 17 heterotopic interstitial pregnancies. BMC Pregnancy Childbirth 2018; 18:78. [PMID: 29587664 PMCID: PMC5870515 DOI: 10.1186/s12884-018-1700-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/15/2018] [Indexed: 12/19/2022] Open
Abstract
Background Heterotopic interstitial pregnancy is a rare variant of heterotopic pregnancies, and it poses challenges in treating the heterotopic pregnancy and preserving the intrauterine pregnancy. However, there is no clear consensus regarding the optimal management. The aim of this study was to investigate the pregnancy outcomes of women diagnosed with heterotopic interstitial pregnancy. Methods A total of 17 women diagnosed with heterotopic interstitial pregnancy between July 2010 and December 2015 were included. General characteristics of each patient, including age, gravidity and parity, history of pelvic inflammatory disease or surgery, and especially the corresponding therapeutic interventions, were retrospectively analyzed. Moreover, pregnancy outcomes were further followed by face-to-face interview. Results Of the 17 patients, 10 (58.5%) underwent surgical treatment (7 laparoscopic cornual resection, and 3 laparotomy); and 3 cases simultaneously terminated the intrauterine pregnancy by suction evacuation. Compared with laparotomy, laparoscopic cornual section showed shorter operative time (median 40 vs. 70 min), less blood loss (150 vs. 400 ml) and shorter hospital stay (2 vs. 4 days). In addition, 4 (23.5%) patients underwent selective embryo reduction under transvaginal ultrasound guidance. Expectant management was chosen in the remaining 3 patients. In the follow-up study, other than a case of missed miscarriage, the other 13 women who remained committed to their pregnancies all delivered healthy babies either by caesarean section or vaginal birth. No congenital anomalies were reported, and all the infants were in good growth and development. Conclusions Laparoscopic cornual resection is a feasible approach with favorable surgical and long-term pregnancy outcomes. Additionally, medical or expectant management may be a viable treatment option for selected symptom-free patient. Although the survival of the intrauterine pregnancy could not always be assured, the prognosis for a woman with heterotopic interstitial pregnancy is generally good.
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Affiliation(s)
- Yuan Jiang
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, China.,Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Jie Chen
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, China.,Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Huaijun Zhou
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, China.,Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Mingming Zheng
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Ke Han
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Jingxian Ling
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Xianghong Zhu
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Xiaoqiu Tang
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Rong Li
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Ying Hong
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, China. .,Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China.
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Abstract
Interstitial ectopic pregnancy is a rare type of tubal pregnancy that poses diagnostic challenge. It is associated with the highest risk of massive, uncontrollable bleeding and can result in uterine rupture in the second trimester. This is a rare case of unruptured interstitial ectopic diagnosed in the first trimester by ultrasonography and managed medically with systemic methrotrexate and serial ultrasound monitoring.`
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Effect of method of anesthesia on the reproductive and obstetric outcomes of heterotopic pregnancies. Int J Obstet Anesth 2018; 34:73-78. [PMID: 29352623 DOI: 10.1016/j.ijoa.2017.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 12/01/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Anesthesia is commonly used for surgical termination of the extrauterine component of heterotopic pregnancy. We sought to evaluate the effects of general and regional anesthesia during salpingectomy on reproductive and obstetric outcomes of heterotopic pregnancies. METHODS A two-center, retrospective cohort study was conducted, and 49 heterotopic pregnancies were included. Baseline characteristics, reproductive and obstetric outcomes were compared between the general anesthesia and regional anesthesia groups. RESULTS Baseline characteristics were comparable for age, weeks of gestation at diagnosis, and duration of anesthesia. No significant difference was found in pregnancy outcome, perinatal outcome or neonatal weight (P >0.05). The rate of miscarriage in the general anesthesia group was 23.5% versus the regional anesthesia group 15.6% (P >0.05). CONCLUSION With respect to reproductive and obstetric outcomes, this retrospective study found no difference between general anesthesia and regional anesthesia used for early heterotopic pregnancy.
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Yu L, Xu L, Xu X. Treatment of cornual pregnancy in a patient with adenomyosis by high-intensity focused ultrasound (HIFU) ablation: A case report. Medicine (Baltimore) 2017; 96:e8874. [PMID: 29310371 PMCID: PMC5728772 DOI: 10.1097/md.0000000000008874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/31/2017] [Accepted: 11/04/2017] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cornual ectopic pregnancy in adenomyosis patients is a rare clinical condition, which may require careful approach for accurate diagnosis and treatment. PATIENT CONCERNS A 38-year-old woman presented with amenorrhea for 8 weeks and serum HCG levels of 1455 mmol/L. The B ultrasound showed an endometrial thickness of 1.7 cm, and the presence of a cystic structure (16 6 mm) at the right uterine horn. Color Doppler flow imaging (CDFI) accurately detected and confirmed the position of the cystic structure with its clear boundaries. DIAGNOSES Cornual ectopic pregnancy in adenomyosis. INTERVENTIONS The diagnosis was confirmed and treated by HIFU ablation. Total ablation was performed for 738 seconds without any bleeding. OUTCOMES Serum HCG levels decreased to < 0.1 mmol/L after 60 days post operation, and follow-up for 11 months showed a regular menstrual cycle without dysmenorrhea. Gestational sac was not obvious at postoperative 90 days by MRI. The adenomyosis associated lesion with blood perfusion became smaller at postoperative 90 days. LESSONS In this case, we successfully performed HIFU ablation and treated the cornual ectopic pregnancy in an adenomyosis patient for the first time, without any adverse complications.
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Durur-Karakaya A, Seker M, Durur-Subasi İ. Diffusion-weighted imaging in ectopic pregnancy: ring of restriction sign. Br J Radiol 2017; 91:20170528. [PMID: 29023142 DOI: 10.1259/bjr.20170528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To demonstrate the diffusion-weighted imaging (DWI) findings of ectopic pregnancy (EP) and introduce the "ring of restriction" sign by discussing possible causes. METHODS Between January 2014 and January 2017, patients with EP and examined by MRI on a 3T scanner were retrospectively evaluated. MRI and DWI findings were recorded. RESULTS A total of 40 patients were diagnosed with EP at our university hospital, 8 of whom (20%) were evaluated by MRI and DWI. All of them were haemodynamically and clinically stable and could be imaged adequately. Locations were ovary (n = 3, 37.5%), tuba (n = 2, 25%), Caesarean section scar (n = 2, 25%) and parauterine (n = 1, 12.5%). In all eight EPs, the gestational sac diameter was compatible with 7-9 weeks. With DWI, the gestational sac was seen as a thick-walled cyst-like structure. The thick wall showed diffusion restrictions in all patients (ring of restriction sign). CONCLUSIONS DWI through its cellular and molecular evidence may contribute diagnosis of EP. Advances in knowledge: Being aware of the EP wall shows diffusion restriction (ring of restriction) avoids interpretation errors especially in appropriate clinical setting with no need for contrast material.
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Affiliation(s)
- Afak Durur-Karakaya
- 1 Department of Radiology, Faculty of Medicine, Istanbul Medipol University , Istanbul, Turkey
| | - Mehmet Seker
- 1 Department of Radiology, Faculty of Medicine, Istanbul Medipol University , Istanbul, Turkey
| | - İrmak Durur-Subasi
- 2 University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Clinic of Radiology , Ankara, Turkey xs
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Rao A. Potential imaging findings following assisted reproduction: complications and clinical implications. Emerg Radiol 2017; 25:73-86. [PMID: 28988371 DOI: 10.1007/s10140-017-1561-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/28/2017] [Indexed: 11/24/2022]
Abstract
Recent rapid advances in assisted reproduction (ART) have led to global increase in usage of in vitro fertilization. This in turn has resulted in clinicians and imaging specialists encountering increase in complications associated with ART. The specialists dealing with infertility should be aware of potential complications associated with ART. Early diagnosis of these problems is based on clinician's suspicion and radiologist's awareness of these complications. Many of these conditions may be life threatening. Hence, early diagnosis and treatment of these complications can safeguard the fetal and maternal health.
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Affiliation(s)
- Anuradha Rao
- Associate Consultant, Apollo Hospitals, Bangalore, Karnataka, 560078, India.
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Histed SN, Deshmukh M, Masamed R, Jude CM, Mohammad S, Patel MK. Ectopic Pregnancy: A Trainee's Guide to Making the Right Call: Women's Imaging. Radiographics 2017; 36:2236-2237. [PMID: 27831839 DOI: 10.1148/rg.2016160080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Stephanie N Histed
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Monica Deshmukh
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Rinat Masamed
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Cecilia M Jude
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Shaden Mohammad
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Maitraya K Patel
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
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Phillips CH, Wortman JR, Ginsburg ES, Sodickson AD, Doubilet PM, Khurana B. First-trimester emergencies: a radiologist's perspective. Emerg Radiol 2017; 25:61-72. [PMID: 28948411 DOI: 10.1007/s10140-017-1556-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/13/2017] [Indexed: 12/27/2022]
Abstract
The purpose of this article is to help the practitioner ensure early diagnosis and response to emergencies in the first trimester by reviewing anatomy of the developing embryo, highlighting the sonographic appearance of common first-trimester emergencies, and discussing key management pathways for treating emergent cases. First-trimester fetal development is a stepwise process that can be challenging to evaluate in the emergency department (ED) setting. This is due, in part, to the complex anatomy of early pregnancy, subtlety of the sonographic findings, and the fact that fewer than half of patients with ectopic pregnancy present with the classic clinical findings of a positive pregnancy test, vaginal bleeding, pelvic pain, and tender adnexa. Ultrasound (US) has been the primary approach to diagnostic imaging of first-trimester emergencies, with magnetic resonance imaging (MRI) and computed tomography (CT) playing a supportive role in a small minority of cases. Familiarity with the sonographic findings diagnostic of and suspicious for early pregnancy failure, ectopic pregnancy, retained products of conception, gestational trophoblastic disease, failed intrauterine devices, and complications associated with assisted reproductive technology (ART) is critical for any emergency radiologist. Evaluation of first-trimester emergencies is challenging, and knowledge of key imaging findings and familiarity with management pathways are needed to ensure early diagnosis and response.
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Affiliation(s)
- Catherine H Phillips
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Jeremy R Wortman
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Elizabeth S Ginsburg
- Department of Infertility and Reproductive Surgery, Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Aaron D Sodickson
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Peter M Doubilet
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Bharti Khurana
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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