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Astruc A, Paulus A, Jouffray C, Bouet PE, Legendre G. Cervical ectopic pregnancy: A case report of a massive pregnancy with a minimally invasive blood-free treatment and a review of the literature. J Gynecol Obstet Hum Reprod 2024; 53:102837. [PMID: 39151792 DOI: 10.1016/j.jogoh.2024.102837] [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: 04/25/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 08/19/2024]
Abstract
Cervical ectopic pregnancy is one of the rarest types of pregnancy, representing less than 1 % of ectopic pregnancies. We report the case of minimally invasive management of a voluminous cervical ectopic pregnancy at 9 weeks gestation using uterine artery embolization and in situ methotrexate. During follow-up, we encountered no hemorrhagic complications, while β-hCG values returned to normal by Day 104 and the uterine cavity fully recovered within 6 months. Additionally, we present a review of the literature on this topic.
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Affiliation(s)
- Audrey Astruc
- Department of Gynecology and Obstetrics, Angers University Hospital, France.
| | - Azélie Paulus
- Department of Gynecology and Obstetrics, Angers University Hospital, France
| | | | | | - Guillaume Legendre
- Department of Gynecology and Obstetrics, Angers University Hospital, France
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Stabile G, Cracco F, Zinicola G, Carlucci S, Mangino FP, Stampalija T, Ricci G. Subserosal pregnancy: Systematic review with proposal of new diagnostic criteria and ectopic pregnancy classification. Eur J Obstet Gynecol Reprod Biol 2024; 297:254-259. [PMID: 38701545 DOI: 10.1016/j.ejogrb.2024.04.037] [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] [Received: 07/16/2023] [Revised: 04/24/2024] [Accepted: 04/28/2024] [Indexed: 05/05/2024]
Abstract
Ectopic pregnancy (EP) is a pregnancy where the growing blastocyst implants outside the endometrial cavity. EP account approximately for 0.5-1% of all pregnancies, and extrauterine implant is the leading cause of woman mortality in the first trimester of gestation. Non-tubal pregnancies (NTP) account for less than 5% of all EP. NTP are accompanied by a 7-8 times higher risk of maternal mortality when compared to tubal pregnancies, and their treatment might sometimes be very challenging. Subserosal pregnancy (SP) has been defined as rare variant of intramural pregnancy, where a portion of the gestational sac was surrounded only by the serosa of the uterus. Whereas the treatment of the ectopic pregnancies is crucial for patients' lives and for adequate fertility sparing and considering the need for surgical treatment in many cases, an early diagnosis is important; thus we believe it g might be useful to define some criteria to guide subserosal pregnancy identification, and to distinguish it from other types of non-tubal ectopic pregnancy. A systematic review on Pubmed, Scopus, Web of Science and Google Scholar was performed. Case reports, randomized controlled trials, prospective controlled studies, prospective cohort studies, retrospective studies, and case series were considered eligible. In all databases mentioned were considered manuscripts published from 1990 up to March 2023. Only four articles were eligible for inclusion in this review. All patients underwent to surgical management in laparoscopy. The main risk factors for this type of ectopic pregnancy were previous uterine surgery with opening of the endometrial cavity and assisted reproductive techniques procedures. Considering our results, we propose new classification and diagnostic criteria for subserosal pregnancy, to distinguish it from other types of non-tubal ectopic pregnancies with the aim to preserve fertility following the most correct management.
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Affiliation(s)
- Guglielmo Stabile
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy.
| | - Francesco Cracco
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy
| | - Giulia Zinicola
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Stefania Carlucci
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | | | - Tamara Stampalija
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy; Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34100 Trieste, Italy
| | - Giuseppe Ricci
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy; Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34100 Trieste, Italy
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Di Carlofelice M, Vress D. Neo-adjuvant methotrexate to aid minimally invasive surgery in cervical ectopic pregnancy: A case report. Case Rep Womens Health 2024; 41:e00593. [PMID: 38487376 PMCID: PMC10937223 DOI: 10.1016/j.crwh.2024.e00593] [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: 02/07/2024] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 03/17/2024] Open
Abstract
Cervical ectopic pregnancies account for <1% of ectopic pregnancies. Early diagnosis may reduce the morbidity and mortality associated with treatment. A 43-year-old woman, gravida 4 para 2, presented at 5 + 6 weeks of gestation of pregnancy via in vitro fertilisation with painless vaginal bleeding. Her initial serum β-hCG level was 51,495 mIU/mL. Ultrasound showed a live ectopic pregnancy within the upper cervical canal with no sliding sign. Surgery was avoided initially due to risk of haemorrhage. Multi-dose systemic intramuscular methotrexate was used in an alternate-day regimen with rescue folic acid to arrest further pregnancy development. Repeat ultrasound seven days later showed absent cardiac activity. Serum β-hCG remained high at 91,764 mIU/mL. A suction dilatation and curettage was performed to remove the pregnancy from the cervix, with an estimated blood loss of 50 mL. The patient was discharged and her serum β-hCG declined to an undetectable level over three months of follow-up. This case adds to the small body of evidence in the management of live cervical ectopic pregnancy. Neo-adjuvant multi-dose methotrexate was successfully used to reduce the risk of haemorrhage associated with surgical management.
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Affiliation(s)
- Matteo Di Carlofelice
- Department of Obstetrics & Gynaecology, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory 2605, Australia
| | - Danica Vress
- Department of Obstetrics & Gynaecology, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory 2605, Australia
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Xu C, Mao Z, Tan M, Mazhari SA, Ghorbani Vajargah P, Karkhah S, Izadi F, Rouhi P. Prevalence and Related Factors of Rupture among Cases with Ectopic Pregnancy; a Systematic Review and Meta-Analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 12:e2. [PMID: 38022716 PMCID: PMC10674071 DOI: 10.22037/aaem.v11i1.2172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Introduction In the absence of timely treatment, the risk of rupture in patients with ectopic pregnancy (EP) increases, which is associated with extensive bleeding, complicated surgery, and maternal death. This study aimed to investigate the prevalence of rupture and its related factors among EP cases. Methods A comprehensive, systematic search was conducted in electronic databases, such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex, and Scientific Information Database using keywords extracted from Medical Subject Headings such as "Ectopic pregnancies", "Extrauterine pregnancies", and "Ruptured ectopic pregnancy" from the earliest to the 13th of December 2022. The CMA program, version 3, was utilized for analysis. The overall effect size was calculated using the sample size and the frequency of rupture in each of the studies. Heterogeneity was measured using the I2 statistics. Results A total of 5,269 women with EP participated in 17 studies. The pooled prevalence of rupture was 56.4% (95%CI: 44.9% to 67.2%; I2=98.09%; P<0.001). Factors such as number of parties, amount of β-hCG, age, history of ectopic pregnancy, cornual and isthmic pregnancies, gestational age, number of gravidities, history of tubal ligation, tubal diameters, periods of infertility, history of infertility, pregnancy by ovulation induction, extensive hemoperitoneum, ampullar and isthmic pregnancies, ampullar pregnancies, preoperative heart rate (HR), triage, triage shock index (SI), abdominal pain, single marital status, preoperative hemoglobin levels, preoperative hematocrit levels, history of pelvic inflammatory disease (PID), and use of contraceptives were associated with the prevalence of rupture in EP cases. Conclusion Based on the findings, 56.4% of EP cases experienced rupture and various factors influence its prevalence. As a result, health managers and policymakers can address and mitigate modifiable factors contributing to rupture in EP cases by implementing regular consultations and screenings.
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Affiliation(s)
- Chenchen Xu
- Department of gynecology and obstetrics, Changzhou Maternal and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000 China
| | - Zhilei Mao
- Department of gynecology and obstetrics, Changzhou Maternal and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000 China
| | - Mi Tan
- Department of gynecology and obstetrics, Changzhou Maternal and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000 China
| | | | - Pooyan Ghorbani Vajargah
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | - Samad Karkhah
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | - Fatemeh Izadi
- Department of Nursing, School of Nursing and Midwifery, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Parisa Rouhi
- Student Research Committee, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Fu Y, Zhang W, Wang Q, Hu C, Li Q, Huang J. Evaluation of Guidelines and Consensus on Ectopic Pregnancy Based by AGREE II Method. Int J Womens Health 2023; 15:1367-1374. [PMID: 37667774 PMCID: PMC10475285 DOI: 10.2147/ijwh.s421956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023] Open
Abstract
Introduction To evaluate the methodological quality of diagnosis and treatment guidelines/consensus related to ectopic pregnancy. Materials and methods Use the "Appraisal of Guidelines and Research and Evaluation" (AGREE II) method to evaluate the differences among the guideline/consensus. Results We appraised 9 clinical practice guidelines for ectopic pregnancy (9 clinical practice guidelines from 5 countries) including the United States, United Kingdom, Ireland, Canada, and China. The guidelines received the highest scores for clarity of presentation (82.72%) and lowest scores for editorial independence (30.56%). The comprehensive recommendations of the 7 guidelines were Grade B, the other 2 guidelines were Grade C. Conclusion The overall quality of the ectopic pregnancy guidelines had room for improvement. It is recommended to supplement and improve the four fields of "independence", "rigor", "participants" and "application", especially the "independence" and "application" fields.
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Affiliation(s)
- Yiran Fu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Weishe Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
- Hunan Engineering Research Center of Early Life Development and Disease Prevention, Changsha, People’s Republic of China
| | - Qi Wang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Caihong Hu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Qi Li
- Reproductive Medicine Center, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Jingrui Huang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
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Ghoubara ASM, Elsheikh JSA, Abdulwahab HR, Taha AAA. Intra-amniotic and systemic administration of methotrexate with concomitant surgical evacuation of 11 + 5 weeks cervical ectopic pregnancy: a case report. BMC Pregnancy Childbirth 2023; 23:486. [PMID: 37393228 DOI: 10.1186/s12884-023-05794-0] [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: 10/24/2022] [Accepted: 06/15/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Cervical pregnancy is a rare type of ectopic pregnancy. The management of cervical pregnancy is challenging because of the rarity of the condition, late presentation, which is associated with increased risk of failed medical treatment, and excessive post-evacuation bleeding that may require hysterectomy. There is no good evidence in the literature regarding the pharmacological management of living cervical ectopic pregnancy of more than 9 + 0 weeks of gestation, and there is no standard protocol on methotrexate doses in these cases. CASE PRESENTATION We present this case to describe a concomitant medical and surgical management of a living 11 + 5 weeks cervical pregnancy. The initial beta-human chorionic gonadotropins (ß-hCG) serum level was 108,730 IU/L. The patient received 60 mg of methotrexate intra-amniotically followed by another dose of 60 mg of methotrexate intramuscularly 24 h later. Fetal heartbeats stopped on day 03. On day 07, the ß-hCG was 37,397 IU/L. On day 13, the patient had evacuation of the remaining products of conception with the insertion of an intracervical Foley catheter to minimize the bleeding. On day 34, the ß-hCG was negative. CONCLUSION The concomitant use of methotrexate to induce fetal demise along with surgical evacuation may be considered in the management of advanced cervical pregnancy to avoid excessive blood loss, and ultimately hysterectomy.
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Xie Z, Wang Y, Chen R. Persistent cornual pregnancy mimicking uterine arteriovenous malformation: a case report. BMC Womens Health 2023; 23:314. [PMID: 37328873 PMCID: PMC10276523 DOI: 10.1186/s12905-023-02450-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/24/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Uterine arteriovenous malformation(AVM) refers to the abnormal direct traffic between uterine arteries and veins, which can be characterized by the imaging examination, showing increased uterine vascularity and arteriovenous shunting. However, similar imaging manifestations can also be seen in a variety of conditions including retained production of conception, gestational trophoblastic disease, placental polyp, and vascular neoplasm. CASE PRESENTATION Here we present a case of a 42-year-old woman who was suspected of suffering uterine AVM indicated by Doppler sonography and magnetic resonance imaging but was finally diagnosed with a persistent ectopic pregnancy located on the right uterine corner by pathology after laparoscopy. She recovered well after surgery. CONCLUSION Uterine AVM is a rare and serious condition. In general, it presents special radiological manifestations. However, when complicated with other diseases it can also be distorting. Standardized diagnosis and management are important.
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Affiliation(s)
- Zhuolin Xie
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yang Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Rong Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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Yang X, Zheng W, Wei X, Ma J, Yan J, Poon LC, Yang H. Management of cesarean scar pregnancy: Importance of gestational age at diagnosis and disease type-A single center's 5 years of experience involving 223 cases. Front Surg 2023; 10:1055245. [PMID: 36874460 PMCID: PMC9975341 DOI: 10.3389/fsurg.2023.1055245] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/19/2023] [Indexed: 02/17/2023] Open
Abstract
Objective This study aims to evaluate the importance of the gestational age at diagnosis and the types of cesarean scar pregnancy (CSP) for treatment outcomes and to identify the optimal treatment based on both the gestational age at diagnosis and the CSP type. Methods A retrospective cohort study included 223 pregnant women diagnosed with CSP at Peking University First Hospital, Beijing, China, between 2014 and 2018. All CSP cases underwent ultrasound-guided vacuum aspiration followed by supplementary curettage. Adjuvant treatment modalities included intramuscular injection of systemic methotrexate, uterine artery embolization, and hysteroscopy before ultrasound-guided vacuum aspiration. Linear regression was used to determine the relationship between intraoperative blood loss and gestational age at diagnosis, CSP type, highest β-human chorionic gonadotropin level, and management procedures. Results None of the patients required blood transfusions or hysterectomies. Patients presenting at <8, 8-10, and >10 weeks had median estimated blood loss of 5, 10, and 35 ml, respectively. Patients with type I CSP, type II CSP, and type III CSP had median blood loss of 5, 5 and 10 ml, respectively. Multivariate linear regression analysis demonstrated that the gestational age at diagnosis (p < 0.001) and type of CSP (p = 0.023) were independent predictors of intraoperative estimated blood loss. For type I CSP patients, ultrasound-guided vacuum aspiration followed by supplementary curettage alone was performed in 15 of 34 (44.1%) patients, including 12/27 (44.4%) diagnosed at <8 weeks, 2/6 (33.3%) at 8-10 weeks, and 1/1 for >10 weeks. In type II CSP patients, fewer cases were managed by ultrasound-guided vacuum aspiration followed by supplementary curettage alone as the gestational age at diagnosis increased [18/96 (18.8%) for <8 weeks, 7/41 (17.1%) for 8-10 weeks, none for >10 weeks]. Most type III CSP patients (41/45, 91.1%) needed treatments in addition to the ultrasound-guided vacuum aspiration regardless of the gestational age at diagnosis. All CSP patients were treated successfully and did not require readmission or further medical interventions. Conclusion Gestational age at diagnosis of CSP and its type show a strong correlation with estimated blood loss during ultrasound-guided vacuum aspiration. With careful management, CSPs may be treated at any gestational week, regardless of their type, with minimal intraoperative bleeding.
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Affiliation(s)
- Xinrui Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Weiran Zheng
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Xiaoyu Wei
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Jingmei Ma
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Jie Yan
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Liona C Poon
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
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Cirillo F, Paladino I, Ronchetti C, Busnelli A, Morenghi E, Grilli L, Patrizio P, Zannoni E, Levi-Setti PE. Ectopic pregnancy risk factors in infertile patients: a 10-year single center experience. Sci Rep 2022; 12:20473. [PMID: 36443354 PMCID: PMC9705323 DOI: 10.1038/s41598-022-24649-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/18/2022] [Indexed: 11/29/2022] Open
Abstract
The present retrospective study included both intrauterine insemination and in vitro assisted reproductive technologies (ART) procedures performed from January 2009 to December 2018 at a tertiary-care Fertility Centre. The purpose was to assess the incidence of ectopic pregnancy (EP) in infertile population who undergoes ART and to identify any risk factor impacting the occurrence of EP after ART. Among 27,376 cycles, 7352 pregnancies were achieved, of which 132 were EPs, the 1.80% (95% CI 1.5-2.1) of all pregnancies. In fresh embryo transfer cycles, a history of prior pelvic adhesions showed the greatest impact on the incidence of EP (aOR 2.49 95% CI 1.53-4.07 p < 0.001). Other factors associated with EP incidence were also identified, such as female age, basal FSH, the transfer of blastocyst embryos and difficulties during the embryo transfer procedure. In frozen embryo transfer cycles, the only factor influencing the incidence of EP was anti Müllerian hormone (AMH) serum concentration (aOR 0.81 95% CI 0.65-1.00, p = 0.048). To conclude, the incidence of EP observed was comparable to that reported after natural conception. On the other hand, pre-existing risk factors, traditionally more common in infertile population, appeared to influence the incidence of EP and should thus be modified if possible.
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Affiliation(s)
- Federico Cirillo
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Ilaria Paladino
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Camilla Ronchetti
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Andrea Busnelli
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Emanuela Morenghi
- grid.417728.f0000 0004 1756 8807Biostatistics Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Leonora Grilli
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Pasquale Patrizio
- grid.26790.3a0000 0004 1936 8606Division Reproductive Endocrinology and Infertility, University of Miami, Miller School of Medicine, Miami, FL USA
| | - Elena Zannoni
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Paolo Emanuele Levi-Setti
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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10
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Sorrentino F, Vasciaveo L, De Feo V, Zanzarelli E, Grandone E, Stabile G, Nappi L. Interstitial Pregnancy Treated with Mifepristone and Methotrexate with High Serum β-hCG Level in a Patient Wishing to Preserve Fertility: Time to Define Standardized Criteria for Medical/Surgical Therapy? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11464. [PMID: 36141736 PMCID: PMC9516977 DOI: 10.3390/ijerph191811464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
Interstitial pregnancy (IP) accounts for 2% of all ectopic pregnancies and has a mortality rate of 2-2.5%. The diagnosis is made by a transvaginal ultrasound and the treatment can be medical or surgical. We report the case of a 36-year-old primigravida who was 6 + 5 weeks pregnant, diagnosed with interstitial pregnancy by ultrasound, who had a very high serum β-hCG level (31,298 mIU/mL) and wanted to preserve her fertility. The patient was treated with one dose of mifepristone and a double dose of methotrexate since the decrease in the β-hCG serum level was less than 15% after the first dose. At the beginning, medical therapy was effective, as no embryonal cardiac activity was detected and serum β-hCG levels decreased early, but on the 20th day of hospitalization, the patient underwent surgery for her clinical symptoms and the evidence of free fluid in the Douglas pouch at a transvaginal ultrasound exam. Our experience showed that medical treatment should be considered, especially in women wishing to preserve their fertility. Further studies are needed to establish a standardized protocol and maybe a clinical score that can be useful in predicting the patients in which medical therapy could be most successful.
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Affiliation(s)
- Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Lorenzo Vasciaveo
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Vincenzo De Feo
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Erika Zanzarelli
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Elvira Grandone
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
- Thrombosis and Haemostasis Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy
- Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, 119991 Moscow, Russia
| | - Guglielmo Stabile
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
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11
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Stabile G, Cracco F, De Santo D, Zinicola G, Romano F, De Manzini N, Scomersi S, Ricci G. Spontaneous Bladder Rupture after Normal Vaginal Delivery: Description of a Rare Complication and Systematic Review of the Literature. Diagnostics (Basel) 2021; 11:1885. [PMID: 34679583 PMCID: PMC8534473 DOI: 10.3390/diagnostics11101885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To identify the possible causes of spontaneous bladder rupture after normal vaginal delivery and to propose a diagnostic and therapeutic algorithm. MATERIAL AND METHODS MEDLINE (PubMed), Web of Science and Scopus databases were searched up to August 2020. Manuscripts considered were published from 1990 and only English articles were included. The research strategy adopted included the following terms: (bladder rupture) AND (spontaneous) AND (delivery). 103 studies were identified. Duplicates were found through an independent manual screening. Subsequently, two authors independently screened the full text of articles and excluded those not pertinent to the topic. Discrepancies were resolved by consensus. Finally, thirteen studies were included. RESULTS PRISMA guidelines were followed. For each study, fetal weight, catheterization during labor, parity, maternal age, occurrence time, previous abdominal or pelvic surgery, symptoms complained of, diagnostic methods, and treatment were considered. Median age was 26.0 (range 20-34 years); median presentation time was 3.0 days after delivery (range 1-20 days); and median newborn weight was 3227.0 g (range 2685-3600 g). Catheterization during labor was reported only in four of the thirteen cases (30.8%) identified. The symptoms most frequently complained of were abdominal pain and distension, fever, oliguria, haematuria and vomiting. Instrumental diagnosis was performed using X-rays in five cases and computerized tomography in six cases. Ultrasound was chosen in five cases as a first diagnostic tool. In two cases, cystography was performed. Treatment was always laparotomic repair of the visceral defect. CONCLUSION Abdominal pain, increased creatinine and other signs of kidney failure on blood tests should lead to suspicion of this complication. Cystourethrography is regarded as a procedure of choice, but a first ultrasound approach is recommended. The main factor for the therapeutic choice is the intraperitoneal or extraperitoneal rupture of the bladder. Classical management for intraperitoneal rupture of the bladder is surgical repair and urinary rest.
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Affiliation(s)
- Guglielmo Stabile
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Via dell’Istria 65/1, 34137 Trieste, Italy; (D.D.S.); (F.R.); (G.R.)
| | - Francesco Cracco
- UCO Clinica Ostetrica e Ginecologica, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34137 Trieste, Italy; (F.C.); (G.Z.)
| | - Davide De Santo
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Via dell’Istria 65/1, 34137 Trieste, Italy; (D.D.S.); (F.R.); (G.R.)
| | - Giulia Zinicola
- UCO Clinica Ostetrica e Ginecologica, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34137 Trieste, Italy; (F.C.); (G.Z.)
| | - Federico Romano
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Via dell’Istria 65/1, 34137 Trieste, Italy; (D.D.S.); (F.R.); (G.R.)
| | - Nicolò De Manzini
- SC (UCO) Clinica Chirurgica, Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy; (N.D.M.); (S.S.)
| | - Serena Scomersi
- SC (UCO) Clinica Chirurgica, Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy; (N.D.M.); (S.S.)
| | - Giuseppe Ricci
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Via dell’Istria 65/1, 34137 Trieste, Italy; (D.D.S.); (F.R.); (G.R.)
- UCO Clinica Ostetrica e Ginecologica, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34137 Trieste, Italy; (F.C.); (G.Z.)
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Interstitial Ectopic Pregnancy: The Role of Mifepristone in the Medical Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189781. [PMID: 34574706 PMCID: PMC8472240 DOI: 10.3390/ijerph18189781] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/15/2021] [Indexed: 02/04/2023]
Abstract
Interstitial pregnancy is defined as the presence of a gestational sac in the most proximal section of the fallopian tube. Management of interstitial pregnancy remains a debated topic. Depending on hemodynamic stability, size of pregnancy, depth of surrounding myometrium, and desires for future fertility, interstitial pregnancy can be managed medically or surgically. We reviewed the literature in December 2020 using keywords “interstitial pregnancy”, “medical treatment”, “methotrexate”, and “mifepristone”. Articles published from January 1991 until 2020 were obtained from databases EMBASE, SCOPUS, and PUBMED. We describe the case of a patient with an interstitial pregnancy that was managed with a total medical approach in August 2020 at Burlo Garofolo Hospital. The patient was asymptomatic and hemodynamically stable, with a high level of serum β-hCG (22,272 mUi/mL). We used the combination of methotrexate (MTX) and mifepristone. Medical therapy was effective leading to interstitial pregnancy resolution in 51 days without collateral effects for the patient. We found seven previous cases reported in the literature. Our purpose is to underline the efficacy of medical therapy with systemic multidose MTX associated with a single oral dose of mifepristone and also folinic acid when is present a viable fetus and a high serum β-hCG level.
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Postcoital Vaginal Perforation and Evisceration in Women with No Prior Pelvic Surgery: Laparoscopic Management and Systematic Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189746. [PMID: 34574671 PMCID: PMC8464867 DOI: 10.3390/ijerph18189746] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 11/23/2022]
Abstract
Objective: to evaluate risk factors, causes, management and surgical therapy of postcoital vaginal perforation and evisceration in women with no prior pelvic surgery. Data sources: We used MEDLINE (PubMed), Scopus, Embase and Web of Science for our research. Our review includes all reports from 1980 to November 2020. The research strategy adopted included different combinations of the following terms: (intercourse) AND (coitus) AND (vaginal perforation). Methods of study selection: we report a case of vaginal evisceration after consensual intercourse in a young and healthy woman. In addition, we performed a systematic review of vaginal perforations with or without evisceration in women without prior surgery or any other predisposing disease. All studies identified were listed by citation, title, authors and abstract. Duplicates were identified by an independent manual screening, performed by one researcher and then removed. For the eligibility process, two authors independently screened the title and abstracts of all non-duplicated papers and excluded those not pertinent to the topic. Tabulation, integration and results: We have followed the PRISMA guidelines. Five manuscripts were detected through the references of the works that had been identified with the research on MEDLINE (PubMed), Scopus, Embase and Web of Science. We found 16 cases between 1980 and 2020. The young age and the virginal status represent the principal risk factors and all the lacerations occurred in the posterior vaginal fornix. The most common surgical technique was the laparotomic approach and, in the remaining cases, the laparoscopic and vaginal route was performed. Conclusions: Post-coital vaginal perforation and evisceration in women with no prior pelvic surgery is a rare condition in the clinical practice and, when it is associated with evisceration it is a surgical emergency. Usually, these injuries are not life-threatening conditions but, a delay in diagnosis, can lead to severe complications. In consideration of the high heterogeneity of the data in the literature, it is essential to define a diagnostic–therapeutic management for the patients with vaginal perforation. With our review, we try to identify the associated risk factors, the best and fastest diagnosis, and the best surgical approach. We believe that a combined vaginal and laparoscopic approach can be the best surgical treatment, useful to diagnose injuries of the abdominal organs and to improve postoperative outcome.
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"Nerve-sparing" laparoscopic treatment of parametrial ectopic pregnancy. Fertil Steril 2021; 116:1197-1199. [PMID: 34253326 DOI: 10.1016/j.fertnstert.2021.05.106] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To demonstrate laparoscopic surgical management of parametrial ectopic pregnancy. DESIGN Video presentation of laparoscopic nerve-sparing treatment of parametrial pregnancy. SETTING Tertiary university center. PATIENT(S) A 33-year-old patient, nullipara at 8 weeks of gestation, with no comorbidity and no previous surgery, was admitted to a spoke hospital for acute abdominal pain. During hospitalization, a transvaginal gynecologic ultrasound revealed pregnancy with ectopic localization. Free pelvic fluid was detected, and a subsequent diagnostic laparoscopy was performed because of worsening symptoms. During the procedure, hemoperitoneum drainage was instituted and American Society of Reproductive Medicine stage III pelvic endometriosis was diagnosed. A round formation approximately 3 cm in diameter was found at the left posterior parametrium (Fig. 1). Due to the pregnancy position and β-human chorionic gonadotropic (β-hCG; 820 mUI /mL) values, conservative treatment was chosen. Thus, methotrexate at 50 mg/m2 body surface area was administered. A second dose of methotrexate was administered seven days after the first one, and the β-hCG increased to 1068 mUI. On day 14 after treatment, the β-hCG was 1053 mUI/mL. Therefore, surgical treatment was chosen, and the patient was transferred to our center. An ultrasound assessment confirmed the ectopic pregnancy with a live fetus in the left posterior parametrium. INTERVENTION(S) The patient underwent operative laparoscopy to remove the ectopic pregnancy. Surgery was performed using a 3-dimensional optical system (TIPCAM 1, S D3-LINK; Karl Storz SE & Co., Tuttlingen, Germany). After drainage of the hemoperitoneum, the gestational sac was identified in the left posterior parametrium. The uterus, tubes, and ovaries showed normal morphology. Pelvic endometriosis was confirmed. After accessing the left pelvic retroperitoneum with the medial and lateral pararectal spaces' opening and development, ipsilateral ureterolysis was necessary to isolate the parametrial pregnancy in close contact with it. Coagulation and sectioning of the deep uterine veins were essential to control hemostasis. Identification of the left hypogastric nerve, which was partially infiltrated by the chorionic villi, and the pelvic splanchnic nerves, was required to safeguard them (Fig. 2). Subsequently, the surgeon decided to place a ureteral stent to prevent urologic complications. MAIN OUTCOME MEASURE(S) The laparoscopic approach proved to be safe and feasible to manage parametrial pregnancy. RESULT(S) The pregnancy was removed entirely. The patient was discharged 72 hours after the procedure with an uneventful postoperative course. The histologic report confirmed the diagnosis of parametrial pregnancy on decidualized endometriotic tissue. The β-hCG serum level became negative in 20 days. CONCLUSION(S) Extrauterine pregnancies represent one of the leading causes of maternal death in the first trimester and constitute approximately 1%-2% of total pregnancies. Of these percentages, only 5%-8.3% are nontubal. Cases of abdominal pregnancy are even rarer, estimated at <1%, and among these, according to a recent review, only 20 cases of retroperitoneal pregnancy were described in the literature. The intraoperative finding of multiple endometriotic implants on the parietal peritoneum above the retroperitoneal pregnancy, together with the decidualized endometriosis result of the histologic examination have been considered to explain the pathogenesis of the condition. It is plausible to suppose that endometriosis has represented the access route for the fertilized ovum, which implanted on endometriotic superficial tissue and then moved toward the retroperitoneal vascularized structures. The diagnosis and treatment are challenging for the gynecologist. Medical treatment is a valid approach to uninterrupted early ectopic pregnancies; however, symptomatic patients' medical therapy failure is one indication for a surgical procedure. The laparoscopic method is optimal, especially in cases like the reported one, in which minimally-invasive techniques allowed complete removal of the pregnancy, respecting the anatomic structures of the retroperitoneum using nerve-sparing techniques. Furthermore, it ensured a safe ureteral stent placement without imaging. The laparoscopic surgical approach can be a safe and feasible option. It allows an early discharge, with a minimum risk of dysfunctional complications, and improves life quality compared to more destructive interventions. In conclusion, to control vascular, nervous, and urinary tract structures, surgical treatment should be based on anatomic knowledge of retroperitoneal anatomy to guarantee the best surgical outcome.
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The Rare, Unexpected Condition of a Twisted Leiomyoma in Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome: Etiopathogenesis, Diagnosis and Management. Our Experience and Narrative Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115895. [PMID: 34072739 PMCID: PMC8198036 DOI: 10.3390/ijerph18115895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 12/26/2022]
Abstract
Uterine leiomyomas are a common finding in medical practice, but their frequency changes drastically when contextualized in a syndrome, as in the following case. A 50-year-old woman with a known Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome presented at our clinic with abdominal pain located in the lower quadrants and scarcely responsive to analgesic therapy. A twisted gynecological pelvic mass was diagnosed, and management for prompt resolution was adopted. Histologically the mass was described as a leiomyoma. The aim of the present study is to share our experience and to review the literature to compare different manifestation of the disease and different approach used in the various centers. The additional novelty of the paper is the immunohistochemical study we carried out on the leiomyoma that is contrasted with the current etiopathogenetic theories.
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Pelvic mass, ascites, hydrothorax: a malignant or benign condition? Meigs syndrome with high levels of CA 125. MENOPAUSE REVIEW 2021; 20:103-107. [PMID: 34321989 PMCID: PMC8297628 DOI: 10.5114/pm.2021.106100] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/26/2021] [Indexed: 01/08/2023]
Abstract
Introduction Abdominal-pelvic mass, ascites and pleural effusion are suggestive of malignant metastatic ovarian cancer. This triad is also present in a rare benign condition called Meigs syndrome. Rarely this condition is associated with an increased CA 125 level. Case report A 62-year-old woman with a history of abdominal pain underwent an ultrasound (US) examination and a chest X-ray. The imaging revealed the presence of a large pelvic mass and ascites with a monolateral pleural effusion and a high level of the tumor marker CA 125. The patient underwent a total abdominal hysterectomy, salpingoophorectomy, removal of the pelvic mass, pelvic lymphadenectomy and peritoneal biopsies. The histology showed an ovarian fibrothecoma. Discussion The US analysis according to international ovarian tumor analysis simple rules revealed “inconclusive results”; the logistic regression model LR2 and Adnex suggested a high risk of malignancy. The presence of ascites and the size of the lesion associated with a high level of CA 125 affected the correct assessment of the risk of malignancy, exposing the patient to overtreatment Conclusions Meigs syndrome is characterized by the resolution of symptoms after surgical removal of the pelvic mass. However, it mimics the clinical picture of a malignant metastatic ovarian cancer. Clinicians have to exclude ovarian cancer and recognize the syndrome to reduce inappropriate procedures.
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Cesarean Scar Pregnancy Treated by Artery Embolization Combined with Diode Laser: A Novel Approach for a Rare Disease. ACTA ACUST UNITED AC 2021; 57:medicina57050411. [PMID: 33922785 PMCID: PMC8146286 DOI: 10.3390/medicina57050411] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/12/2021] [Accepted: 04/22/2021] [Indexed: 11/22/2022]
Abstract
Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy which represents a consequence of a previous cesarean section. It is associated with major maternal morbidity and mortality and has potential implications on future fertility. Because of possible serious complications, CSP should be swiftly diagnosed and treated. There is no management protocol for this rare, life-threatening condition, and each patient should be evaluated individually. Several types of conservative treatment have been used to treat cesarean scar pregnancy: dilation and curettage (D&C), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolization with curettage and/or methotrexate administration. In our study we present a cesarean scar pregnancy of a 40-year-old woman who was treated with angiographic uterine artery embolization (UAE) followed by hysteroscopic diode laser resection. Our combined UAE–hysteroscopic laser surgery appears to offer an effective, safe, and minimally invasive surgical treatment.
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Stabile G, Romano F, De Santo D, Sorrentino F, Nappi L, Cracco F, Ricci G. Case Report: Bowel Occlusion Following the Use of Barbed Sutures in Abdominal Surgery. A Single-Center Experience and Literature Review. Front Surg 2021; 8:626505. [PMID: 33959630 PMCID: PMC8093862 DOI: 10.3389/fsurg.2021.626505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/11/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction: A high level of surgical ability is required to perform endoscopic knot tying. Barbed sutures help in avoiding this procedure, thus reducing intraoperative time and lowering blood loss and hospitalization time when compared to traditional sutures. Some cases of bowel occlusion following the use of barbed sutures have been described in literature. All of them are characterized by the entanglement of an intestinal loop in wire barbs with bowel occlusion symptoms. Case Presentation: We report two more cases which occurred in our Institute in 2020 and review those which have been reported in the literature by searching on Pubmed, Scopus, and Embase. We used the search terms: “Barbed,” ”Suture,” “Bowel,” and ”Obstruction.” We examined in the literature the surgical procedures, the type of complications, the time to onset of the complications, and the type of barbed suture. Discussion: Twenty-two cases in total were reported in the literature from 2011 to 2020, and bowel complications were largely subsequent to interventions such as hernia surgical repair and myomectomy. In order to take advantage of barbed sutures while minimizing the risk of adverse events, such as intestinal occlusion, some precautions may be considered, such as the shortening of thread tails and use of antiadhesive barriers. Moreover, performing a few stitches backwards when ending the suture might be a useful suggestion. Further studies in this field may be useful in order to assess whether it might be better avoiding barbed suture application on serosal tissues to prevent bowel damage.
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Affiliation(s)
- Guglielmo Stabile
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico "Burlo Garofolo", Trieste, Italy
| | - Federico Romano
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico "Burlo Garofolo", Trieste, Italy
| | - Davide De Santo
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico "Burlo Garofolo", Trieste, Italy
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Francesco Cracco
- University Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giuseppe Ricci
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico "Burlo Garofolo", Trieste, Italy.,University Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
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