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Aoyagi Y, Kai K, Aso S, Nishida M, Kawano Y. Coexistence of Ovarian Endometrioma and Ovarian Pregnancy: A Case Report. Cureus 2023; 15:e35608. [PMID: 37007423 PMCID: PMC10063240 DOI: 10.7759/cureus.35608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Both ovarian pregnancy and endometrioma can rupture and cause life-threatening hemoperitoneum. However, little is known about their coexistence. We report the case of a 34-year-old Japanese woman with a life-threatening hemoperitoneum in the first trimester coexisting with ovarian endometrioma and ovarian pregnancy. The patient was hospitalized in our department for acute hypogastric pain and massive hemoperitoneum during pregnancy. She had a history of miscarriage at eight weeks of gestation one year prior. Her serum beta-human chorionic gonadotropin (hCG) level was >2,000 mIU/mL. Also, a transvaginal ultrasound showed an empty uterus, an intact right ovary, an inhomogeneous left ovary, and a massive hemoperitoneum. An exploratory laparoscopy revealed a rupture of the left ovarian endometrioma, a left corpus luteal cyst, and intraperitoneal bleeding of approximately 1,200 mL. However, no ectopic lesions were observed. Microscopic examination revealed an endometriotic cyst with decidual changes in the stroma, a corpus luteal cyst, and chorionic villi with hemorrhage. Serum beta-hCG levels became negative on the 27th postoperative day. The postoperative course was uneventful. This case shows that, in addition to the differential diagnosis of ovarian pregnancy from ovarian endometrioma, clinicians should consider the coexistence of both conditions.
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Mamo A, Adkins K. Abdominal Pregnancy: Pathophysiology, Diagnosis, and Treatment. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0013] [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)
- Andrina Mamo
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Katlynn Adkins
- University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Obstetrics and Gynecology, Denver Health and Hospital Authority, Denver, Colorado, USA
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Diagnostic Challenges of an Abdominal Pregnancy in the Second Trimester. Case Rep Obstet Gynecol 2021; 2021:7887213. [PMID: 34395003 PMCID: PMC8355995 DOI: 10.1155/2021/7887213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/24/2021] [Indexed: 11/18/2022] Open
Abstract
Abdominal pregnancies are a rare form of ectopic pregnancy, which presents a significant risk of maternal morbidity and mortality. We describe an unusual case of a late diagnosis of an abdominal pregnancy in the second trimester, which due to diagnostic challenges, was not detected on 1st trimester and subsequent antenatal ultrasound scans (USS). The abdominal pregnancy was later diagnosed at the repeat anomaly scan and confirmed with a pelvic MRI. This case of abdominal pregnancy is unique when compared to other reported cases, as the fetus was initially enclosed within the amniotic sac with normal liquor volume. Both transvaginal and transabdominal scans appeared to demonstrate an intrauterine pregnancy. The diagnosis of abdominal pregnancy was only made possible following rupture of the amniotic sac, leading to anhydramnios, which resulted in the repositioning of the fetus to the upper maternal abdomen. This case represents the challenges faced by obstetricians in diagnosing, managing, and counselling a woman when faced with an abdominal pregnancy.
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Moake MM, Price AB, Titus MO, Barnes RM. Point-of-Care Ultrasound Facilitates Management of Ruptured Ectopic Pregnancy. Pediatr Emerg Care 2021; 37:282-285. [PMID: 33903289 DOI: 10.1097/pec.0000000000002375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Abdominal pain in the pregnant adolescent presents a diagnostic dilemma with potential life-threatening etiologies. We present a case where point-of-care ultrasound was used to facilitate diagnosis and expedite lifesaving management of a ruptured ectopic pregnancy. We further review the technique and literature for first-trimester transabdominal point-of-care ultrasound.
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Affiliation(s)
| | | | | | - Ryan M Barnes
- Emergency Medicine, Medical University of South Carolina, Charleston, SC
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Management of interstitial pregnancy in the era of laparoscopy: a meta-analysis of 855 case studies compared with traditional techniques. Obstet Gynecol Sci 2021; 64:156-173. [PMID: 33539687 PMCID: PMC7990998 DOI: 10.5468/ogs.20299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/27/2020] [Indexed: 11/08/2022] Open
Abstract
Interstitial pregnancy is a rare, life-threatening condition that requires high clinical suspicion for diagnosis. Most cases are discovered after complications have occurred. Many authors have described laparoscopic management. Although previous systematic reviews have compared the attributes and complications associated with interstitial pregnancy, we endeavored to complete the first systematic review and meta-analysis to compare the laparoscopic treatment of interstitial pregnancy with the open approach in the modern age of laparoscopic surgery. We systematically searched PubMed, ClinicalTrials.gov, Scopus, Web of Science, and Cochrane until June 2020 using relevant keywords and screened them for eligibility. We found a statistically significant difference in blood loss between laparoscopic and open surgery (168 mL compared to 1,163 mL). Further, cumulative meta-analysis has revealed that blood loss in laparoscopy has been decreasing over time from 1991 to 2020. Laparoscopic patients took less operative time (63.2 minutes) compared to laparotomy patients (78.2 minutes). Patients in the laparoscopic group spent less time hospitalized (3.7 days) compared to laparotomy patients (5.2 days). Our findings add strength to the position that laparoscopic approaches to interstitial pregnancy can be considered first-line in most situations. The laparoscopic approach was found to have a mean blood loss of 168 mL, and this blood loss seems to decrease over time. Increased gravidity and duration of amenorrhea are positive factors that increase bleeding during the procedure. We are unable to find enough high-quality data to significantly compare successful pregnancy following surgery or risk of mortality in these populations.
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Yüksel D. Rare Types of Ectopic Pregnancies. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2021. [DOI: 10.1007/s13669-020-00303-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Finlinson AR, Bollig KJ, Schust DJ. Differentiating pregnancies near the uterotubal junction (angular, cornual, and interstitial): a review and recommendations. FERTILITY RESEARCH AND PRACTICE 2020; 6:8. [PMID: 32391161 PMCID: PMC7199330 DOI: 10.1186/s40738-020-00077-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/06/2020] [Indexed: 12/02/2022]
Abstract
Eccentrically located intracavitary pregnancies, which include pregnancies traditionally termed as cornual and/or angular, have long presented complex diagnostic and management challenges given their inherent relationship to interstitial ectopic pregnancies. This review uses the existing literature to discriminate among interstitial, cornual, and angular pregnancies. Current arguments propose the outright abandonment of the terms cornual and angular may be justified in favor of the singular term, eccentric pregnancy. Disparate definitions and diagnostic approaches have compromised the literature’s ability to precisely describe prognosis and ideal management practices for each of these types of pregnancies. Standardizing the classification of these pregnancies near the uterotubal junction is important to unify conservative, yet safe and effective management strategies. We advocate the use of early first trimester ultrasound to correctly differentiate between eccentric pregnancy and interstitial ectopic pregnancy as current research suggests substantially better outcomes with correctly diagnosed and expectantly managed eccentric pregnancies than past investigations may have shown. The expectant management of eccentric pregnancies will often result in a healthy term pregnancy, while interstitial ectopic pregnancies inherently have a poor likelihood of progressing to viability. When the terms and diagnosis of cornual, angular, and interstitial pregnancy are indistinct, there is substantial risk of intrauterine pregnancies to be inappropriately managed as ectopic pregnancies. Until we standardize terms and criteria, it will remain difficult, if not impossible, to determine true risk for pregnancy loss, preterm labor, abnormal placentation, and uterine or uterotubal rupture. The development of best practice guidelines will require standardized terminology and diagnostic techniques.
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Affiliation(s)
- Alex R Finlinson
- Department of Obstetrics, Gynecology and Women's Health, MU Institute for Women's Health Research, University of Missouri School of Medicine, 500 North Keene Street, Columbia, MO 65201 USA
| | - Kassie J Bollig
- Department of Obstetrics, Gynecology and Women's Health, MU Institute for Women's Health Research, University of Missouri School of Medicine, 500 North Keene Street, Columbia, MO 65201 USA
| | - Danny J Schust
- Department of Obstetrics, Gynecology and Women's Health, MU Institute for Women's Health Research, University of Missouri School of Medicine, 500 North Keene Street, Columbia, MO 65201 USA
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Dhombres F, Maurice P, Guilbaud L, Franchinard L, Dias B, Charlet J, Blondiaux E, Khoshnood B, Jurkovic D, Jauniaux E, Jouannic JM. A Novel Intelligent Scan Assistant System for Early Pregnancy Diagnosis by Ultrasound: Clinical Decision Support System Evaluation Study. J Med Internet Res 2019; 21:e14286. [PMID: 31271152 PMCID: PMC6636237 DOI: 10.2196/14286] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 01/26/2023] Open
Abstract
Background Early pregnancy ultrasound scans are usually performed by nonexpert examiners in obstetrics/gynecology (OB/GYN) emergency departments. Establishing the precise diagnosis of pregnancy location is key for appropriate management of early pregnancies, and experts are usually able to locate a pregnancy in the first scan. A decision-support system based on a semantic, expert-validated knowledge base may improve the diagnostic performance of nonexpert examiners for early pregnancy transvaginal ultrasound. Objective This study aims to evaluate a novel Intelligent Scan Assistant System for early pregnancy ultrasound to diagnose the pregnancy location and determine the image quality. Methods Two trainees performed virtual transvaginal ultrasound examinations of early pregnancy cases with and without the system. The ultrasound images and reports were blindly reviewed by two experts using scoring methods. A diagnosis of pregnancy location and ultrasound image quality were compared between scans performed with and without the system. Results Each trainee performed a virtual vaginal examination for all 32 cases with and without use of the system. The analysis of the 128 resulting scans showed higher quality of the images (quality score: +23%; P<.001), less images per scan (4.6 vs 6.3 [without the CDSS]; P<.001), and higher confidence in reporting conclusions (trust score: +20%; P<.001) with use of the system. Further, use of the system cost an additional 8 minutes per scan. We observed a correct diagnosis of pregnancy location in 39 (61%) and 52 (81%) of 64 scans in the nonassisted mode and assisted mode, respectively. Additionally, an exact diagnosis (with precise ectopic location) was made in 30 (47%) and 49 (73%) of the 64 scans without and with use of the system, respectively. These differences in diagnostic performance (+20% for correct location diagnosis and +30% for exact diagnosis) were both statistically significant (P=.002 and P<.001, respectively). Conclusions The Intelligent Scan Assistant System is based on an expert-validated knowledge base and demonstrates significant improvement in early pregnancy scanning, both in diagnostic performance (pregnancy location and precise diagnosis) and scan quality (selection of images, confidence, and image quality).
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Affiliation(s)
- Ferdinand Dhombres
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France.,Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France
| | - Paul Maurice
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France.,Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France
| | - Lucie Guilbaud
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Loriane Franchinard
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Barbara Dias
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Jean Charlet
- Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France.,Direction de la Recherche et de l'Innovation, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Eléonore Blondiaux
- Service de Radiologie, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Babak Khoshnood
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Biostatistics and Epidemiology, INSERM, Paris, France
| | - Davor Jurkovic
- Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospital and Institute for Women's Health, University College London, London, United Kingdom
| | - Eric Jauniaux
- Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospital and Institute for Women's Health, University College London, London, United Kingdom
| | - Jean-Marie Jouannic
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France.,Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France
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Yanhua ZMD, Xuefeng LMD, Chenyu WMD, Huixia LMD, Ji-Bin LMD. Clinical Value of Ultrasonography for Monitoring Angular Pregnancy in First-trimester. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY 2019. [DOI: 10.37015/audt.2019.190818] [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] Open
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10
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Early diagnosis of ovarian pregnancy – a case report. GINECOLOGIA.RO 2019. [DOI: 10.26416/gine.26.4.2019.2710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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11
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Liao CY. Distinguishing between interstitial and angular pregnancies: Is there a role for saline infusion sonohysterography? Taiwan J Obstet Gynecol 2018; 57:605-607. [PMID: 30122588 DOI: 10.1016/j.tjog.2018.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Interstitial pregnancy occurs in the intramural segment of the Fallopian tubes, while angular pregnancy is one that is located in one of the lateral angles of the uterine cavity. The differential diagnosis and treatment of these conditions are important. We have used saline infusion sonohysterography (SIS) to help in differential diagnosis. CASE REPORT A 36-year-old female with a case of suspected left interstitial ectopic pregnancy was admitted. Her diagnostic laparoscopy showed no tubal ectopic pregnancy, and D&C demonstrated no villi. She underwent SIS which showed a sac in the interstitial part but close to the tubal ostium. The second case involves a 21-year-old female who was 9-weeks pregnant. Ultrasonography could not differentiate between interstitial and angular pregnancy. SIS clearly demonstrated angular pregnancy with a missed abortion, and therapeutic D&C was done smoothly. CONCLUSION From reviewing past literature, SIS does not appear to have any proven adverse effect on the pregnancy although it is not widely accepted. This article highlights the benefits of using SIS to aid in the differential diagnosis between the two conditions, especially in unusual cases like ours.
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Affiliation(s)
- Chi-Yuan Liao
- Department of Obstetrics and Gynecology, Mennonite Christian Hospital, Hualien, Taiwan.
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12
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Dhombres F, Maurice P, Friszer S, Guilbaud L, Lelong N, Khoshnood B, Charlet J, Perrot N, Jauniaux E, Jurkovic D, Jouannic JM. Developing a knowledge base to support the annotation of ultrasound images of ectopic pregnancy. J Biomed Semantics 2017; 8:4. [PMID: 28137311 PMCID: PMC5282861 DOI: 10.1186/s13326-017-0117-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 01/18/2017] [Indexed: 11/17/2022] Open
Abstract
Background Ectopic pregnancy is a frequent early complication of pregnancy associated with significant rates of morbidly and mortality. The positive diagnosis of this condition is established through transvaginal ultrasound scanning. The timing of diagnosis depends on the operator expertise in identifying the signs of ectopic pregnancy, which varies dramatically among medical staff with heterogeneous training. Developing decision support systems in this context is expected to improve the identification of these signs and subsequently improve the quality of care. In this article, we present a new knowledge base for ectopic pregnancy, and we demonstrate its use on the annotation of clinical images. Results The knowledge base is supported by an application ontology, which provides the taxonomy, the vocabulary and definitions for 24 types and 81 signs of ectopic pregnancy, 484 anatomical structures and 32 technical elements for image acquisition. The knowledge base provides a sign-centric model of the domain, with the relations of signs to ectopic pregnancy types, anatomical structures and the technical elements. The evaluation of the ontology and knowledge base demonstrated a positive feedback from a panel of 17 medical users. Leveraging these semantic resources, we developed an application for the annotation of ultrasound images. Using this application, 6 operators achieved a precision of 0.83 for the identification of signs in 208 ultrasound images corresponding to 35 clinical cases of ectopic pregnancy. Conclusions We developed a new ectopic pregnancy knowledge base for the annotation of ultrasound images. The use of this knowledge base for the annotation of ultrasound images of ectopic pregnancy showed promising results from the perspective of clinical decision support system development. Other gynecological disorders and fetal anomalies may benefit from our approach.
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Affiliation(s)
- Ferdinand Dhombres
- UPMC Medical Faculty (Paris 6), Department of Fetal Medicine in Armand Trousseau Hospital (APHP), INSERM U1142 (LIMICS), 26 Avenue du Dr Arnold Netter, 75012, Paris, UE, France.
| | - Paul Maurice
- UPMC Medical Faculty (Paris 6), Department of Fetal Medicine in Armand Trousseau Hospital (APHP), INSERM U1142 (LIMICS), 26 Avenue du Dr Arnold Netter, 75012, Paris, UE, France
| | - Stéphanie Friszer
- UPMC Medical Faculty (Paris 6), Department of Fetal Medicine in Armand Trousseau Hospital (APHP), INSERM U1142 (LIMICS), 26 Avenue du Dr Arnold Netter, 75012, Paris, UE, France
| | - Lucie Guilbaud
- UPMC Medical Faculty (Paris 6), Department of Fetal Medicine in Armand Trousseau Hospital (APHP), INSERM U1142 (LIMICS), 26 Avenue du Dr Arnold Netter, 75012, Paris, UE, France
| | - Nathalie Lelong
- INSERM U1153 (Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Biostatistics and Epidemiology), Maternité Port Royal, 53 Avenue de l'Observatoire, 75014, Paris, UE, France
| | - Babak Khoshnood
- INSERM U1153 (Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Biostatistics and Epidemiology), Maternité Port Royal, 53 Avenue de l'Observatoire, 75014, Paris, UE, France
| | - Jean Charlet
- APHP DSI, INSERM U1142 (LIMICS), 15, rue de l'École de Médecine, 75006, Paris, UE, France
| | - Nicolas Perrot
- Pyramides Medical Imaging Center, 13 av. de l'Opéra, 75001, Paris, UE, France
| | - Eric Jauniaux
- University College Hospital (UCLH) Department of Obstetrics and Gynaecology, Academic Department of Obstetrics and Gynaecology, University College London (UCL) Institute for Women's Health, 86-96 Chenies Mews, London, WC1E 6HX, UE, UK
| | - Davor Jurkovic
- Department of Obstetrics and Gynaecology, Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospital (UCLH), 235 Euston Road, London, NW1 2BU, UE, UK
| | - Jean-Marie Jouannic
- UPMC Medical Faculty (Paris 6), Department of Fetal Medicine in Armand Trousseau Hospital (APHP), INSERM U1142 (LIMICS), 26 Avenue du Dr Arnold Netter, 75012, Paris, UE, France
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Frates MC, Doubilet PM, Benson CB. To the Editor. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:454-455. [PMID: 26795045 DOI: 10.7863/ultra.15.07056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Mary C Frates
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts USA
| | - Peter M Doubilet
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts USA
| | - Carol B Benson
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts USA
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Fernandez CM, Levine EM. Unusual Ectopic Pregnancies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:454. [PMID: 26795044 DOI: 10.7863/ultra.15.07052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlos M Fernandez
- Department of Obstetrics and Gynecology, Advocate Illinois Masonic Medical Center, Chicago, Illinois USA
| | - Elliot M Levine
- Department of Obstetrics and Gynecology, Advocate Illinois Masonic Medical Center, Chicago, Illinois USA
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