Evaluation of the necessity of laparoscopic repair of a uterine scar defect for cesarean scar pregnancy

Objective This study aimed to determine the risk factors associated with the necessity of laparoscopic scar defect repair for cesarean scar pregnancy (CSP). Methods We retrospectively analyzed 237 patients with CSP who were treated by ultrasound-guided suction curettage and/or laparoscopy in our hospital from April 2012 to November 2019. A total of 199 of these patients underwent ultrasound-guided suction curettage without uterine scar defect repair, while 38 of these patients underwent laparoscopic resection and uterine scar defect repair. We analyzed various clinical variables and compared the efficacy of treatment between the two groups. Results Gestational age, the maximum transverse diameter (MTD) of the gestational sac, myometrial thickness, the operation time, intraoperative blood loss, and the duration of the hospital stay were significantly different between the two groups. Gestational age, the MTD of the gestational sac, and myometrial thickness were independent risk factors for laparoscopic repair. Conclusions Gestational age, the MTD of the gestational sac, and myometrial thickness are important factors associated with the necessity for laparoscopic repair of a uterine scar defect.

Determination of Gestational Age in Shami Goats Based on Transabdominal Ultrasonographic Measurements of Placentomes and Uterine Diameter

The study was aimed to estimate the gestational age of Shami does by transabdominal ultrasonographic measurement of maternal parameters. Thirty-three Shami does aged 2-2.5 years with confirmed conception dates were used. The does were examined in a standing position using a transabdominal 3.5 MHz convex sector probe of real-time ultrasonography. The does were examined weekly starting from 21 days of pregnancy until parturition. Measurements of the maternal parameters that include; the uterine diameter, placental width, and placental height were obtained from the ultrasonographic images using the software Screen Calipers. Results showed that the gestational sac and embryos were observed early on 21 and 35 days of pregnancy. The litter size of Shami does was 2-3 kids. Uterine diameter ranged between 27±1.4 and 136.9±4.2 mm between 21-130 days, placentomes width was 17.6±0.6 – 38.5±2.1 mm, placentomes height was 9.5 ± 1.8 – 24.5 ± 1.4 mm on 51-150 days of gestation. The highest positive correlations were obtained between the gestational age and the measurements of uterine diameter (r=0.943). The least positive correlations were between the gestational age and the values of placenta width (r=0.715) and placentom height (r=0.615). In conclusion, transabdominal ultrasonography is a practical method for pregnancy diagnosis and monitoring of embryo in Shami goats. Also, it is reliable to estimate gestation age from 21 days of pregnancy. The uterine diameter was the best maternal parameter that can be used for the longest period for estimation of Shami goats gestational age.

A case report of heterotopic pregnancy

Heterotopic pregnancy is the presence of both intrauterine and extrauterine (ectopic) implantation as described by Reece in 1983 and is extremely rare. It accounts for 1 per 30000, in natural cycles and 9 per 10000, in assisted reproduction cycles. The aim of this report is to introduce this case as it poses a challenge to diagnosis due to its complex clinical and laboratory findings. A primigravida aged 30 at 6 weeks period of gestation, reported with minimal bleeding per vaginum. On performing a physical examination her vitals were stable and no significant findings were noted except for an enlarged uterus corresponding to 6 weeks with posterior forniceal fullness. Her beta-hCG was 23765 IU/ml and ultrasound showed a live intrauterine gestation with left adnexal mass- likely ectopic gestational sac. Laparoscopy showed a left tubal pregnancy and salpingectomy was done. The postoperative period was uneventful and she was discharged with a single live intrauterine gestation of 6-7 weeks. She carried on with her pregnancy and delivered a healthy baby at term. The diagnosis is possible only in cases when there is a high index of suspicion by the treating clinician. The adnexa must be inspected carefully in the confirmatory ultrasound. The early timely diagnosis gives a good maternal outcome and hence crucial in the management.

Spontaneous heterotopic pregnancy: a case report

Heterotopic pregnancy is defined as multiple gestation in which intrauterine and extrauterine gestational sacs co-exist. The extra uterine gestational sac is most commonly tubal ectopic pregnancy. We presented case of a 26 years old multigravida who presented to emergency with complaints of pain abdomen and giddiness for 2-3 days. She was at period of gestation (POG) 7 weeks and on clinical examination patient was anxious with mild pallor, mildly tachycardiac and blood pressure (BP) was 90/60 mm of Hg. After thorough clinical examination and sonography diagnosis of heterotopic pregnancy with ruptured tubal ectopic was made. She was taken up for Emergency laparotomy after investigations and consent. Left salpingectomy was done and she was discharged with a single intrauterine live pregnancy on 6th post op day. For early detection of cases of heterotopic pregnancy careful evaluation of adnexa is mandatory in early gestation scan.

Embarazo a término en útero bicorne con cuerno rudimentario no comunicante. Reporte de un caso

The bicorne uterus with a rudimentary non-communicating horn may be associated with gynecological and obstetric complications such as infertility, endometriosis, hematometra, urinary tract abnormalities, abortions, and preterm deliveries. Excision of the rudimentary horn should be done outside of pregnancy, with followup during pregnancy, looking for complications. We present the case of a 40-year-old patient, who presented abdominal pain and vaginal bleeding, with a full-term pregnancy in a rudimentary non-communicating horn of a bicorne uterus. Physical examination showed abdominal distention and loss of uterine contour and no fetal parts were palpated. The provisional diagnosis of rupture of the uterus was made. Emergency laparotomy revealed a dead and deformed fetus, 37 weeks old, in a bicorne uterus with a broken rudimentary non-communicating horn, along with an acretic placenta. Extraction of the gestational sac, fetus and placenta and subtotal hysterectomy with conservation of the left annex were performed. Keywords: Rudimentary horn not communicating, Bicornuate uterus, Term pregnancy

Evaluation of the Treatment of High Intensity Focused Ultrasound Combined With Suction Curettage for Exogenous Cesarean Scar Pregnancy

Purpose: To evaluate the effectiveness of high intensity focused ultrasound (HIFU) combined with suction curettage in the treatment of exogenous cesarean scar pregnancy (CSP). Methods: A total of 41 patients diagnosed with exogenous CSP were enrolled in this study. All patients received HIFU treatment combined with suction curettage. Results: Twenty-nine patients were administered one session of HIFU ablation. In addition, the other 12 patients received 2 HIFU sessions. Suction curettage was performed in all patients after HIFU, and no patient was converted to laparoscopy or hysterectomy. The mean blood loss during suction curettage was 99 ml. Three patients received two sessions of suction curettage. The success rate of our study was 92.68%. The mean time for serum β-HCG normalization was 23.18±3.13 days. The average menstruation recovery time was 29.38±3.34 days. Based on the blood loss during suction curettage, 41 patients were divided into a bleeding group and a control group. The size of the gestational sac in the bleeding group (3.80±0.87 cm) was larger than that in the control group (3.39±0.77 cm) (P <0.05). The thickness of the myometrium between the bladder and gestational sac in the bleeding group (2.37±0.89 mm) was less than that in the control group (2.75±0.75 mm) (P <0.05). Conclusion: The results suggested that HIFU combined with suction curettage could be considered an effective treatment for exogenous CSP of < 9 weeks. The size of the gestational sac and the thickness of the myometrium between the bladder and gestational sac might be high-risk factors for blood loss during this treatment.

Pitfalls in Diagnosing Heterotopic Pregnancy in Sub-Saharan Africa: A Case Report at the Yaounde University Teaching Hospital (Cameroon)

Heterotopic pregnancy (HP) is a dizygotic twin pregnancy in which one gestational sac is intrauterine and the other is extrauterine. The prevalence of HP is unknown in Cameroon where the diagnosis is difficult and usually fortuitous like in other resource-poor settings. We herein depict pitfalls and delays in the diagnosis and management of a ruptured heterotopic pregnancy at the Yaounde University Teaching Hospital. After a wrong diagnosis and inadequate treatment, our patient presented at our emergency unit with severe pelvic pain and clinical signs of hemoperitoneum with shock. She underwent a total left salpingectomy through laparotomy. She had a complete spontaneous abortion five days after the surgery. Given that sonography is not routinely available in emergency departments in resource-poor settings, it may be relevant for practitioners to always bear HP in mind when facing ruptured ectopic pregnancies.

Mifepristone and misoprostol versus placebo and misoprostol for resolution of miscarriage in women diagnosed with missed miscarriage: the MifeMiso RCT

Trial design A randomised, parallel-group, double-blind, placebo-controlled multicentre study with health economic and nested qualitative studies to determine if mifepristone (Mifegyne®, Exelgyn, Paris, France) plus misoprostol is superior to misoprostol alone for the resolution of missed miscarriage. Methods Women diagnosed with missed miscarriage in the first 14 weeks of pregnancy were randomly assigned (1 : 1 ratio) to receive 200 mg of oral mifepristone or matched placebo, followed by 800 μg of misoprostol 2 days later. A web-based randomisation system allocated the women to the two groups, with minimisation for age, body mass index, parity, gestational age, amount of bleeding and randomising centre. The primary outcome was failure to pass the gestational sac within 7 days after randomisation. The prespecified key secondary outcome was requirement for surgery to resolve the miscarriage. A within-trial cost-effectiveness study and a nested qualitative study were also conducted. Women who completed the trial protocol were purposively approached to take part in an interview to explore their satisfaction with and the acceptability of medical management of missed miscarriage. Results A total of 711 women, from 28 hospitals in the UK, were randomised to receive either mifepristone plus misoprostol (357 women) or placebo plus misoprostol (354 women). The follow-up rate for the primary outcome was 98% (696 out of 711 women). The risk of failure to pass the gestational sac within 7 days was 17% (59 out of 348 women) in the mifepristone plus misoprostol group, compared with 24% (82 out of 348 women) in the placebo plus misoprostol group (risk ratio 0.73, 95% confidence interval 0.54 to 0.98; p = 0.04). Surgical intervention to resolve the miscarriage was needed in 17% (62 out of 355 women) in the mifepristone plus misoprostol group, compared with 25% (87 out of 353 women) in the placebo plus misoprostol group (risk ratio 0.70, 95% confidence interval 0.52 to 0.94; p = 0.02). There was no evidence of a difference in the incidence of adverse events between the two groups. A total of 42 women, 19 in the mifepristone plus misoprostol group and 23 in the placebo plus misoprostol group, took part in an interview. Women appeared to have a preference for active management of their miscarriage. Overall, when women experienced care that supported their psychological well-being throughout the care pathway, and information was delivered in a skilled and sensitive manner such that women felt informed and in control, they were more likely to express satisfaction with medical management. The use of mifepristone and misoprostol showed an absolute effect difference of 6.6% (95% confidence interval 0.7% to 12.5%). The average cost per woman was lower in the mifepristone plus misoprostol group, with a cost saving of £182 (95% confidence interval £26 to £338). Therefore, the use of mifepristone and misoprostol for the medical management of a missed miscarriage dominated the use of misoprostol alone. Limitations The results from this trial are not generalisable to women diagnosed with incomplete miscarriage and the study does not allow for a comparison with expectant or surgical management of miscarriage. Future work Future work should use existing data to assess and rank the relative clinical effectiveness and safety profiles for all methods of management of miscarriage. Conclusions Our trial showed that pre-treatment with mifepristone followed by misoprostol resulted in a higher rate of resolution of missed miscarriage than misoprostol treatment alone. Women were largely satisfied with medical management of missed miscarriage and would choose it again. The mifepristone and misoprostol intervention was shown to be cost-effective in comparison to misoprostol alone. Trial registration Current Controlled Trials ISRCTN17405024. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 68. See the NIHR Journals Library website for further project information.

Variance in clinical presentation of Ectopic pregnancy

Objective: To adjudge the prevalence of distinct presentations in ectopic pregnancy. Research Design: Descriptive cross-sectional. Place and Duration of Study: Emergency Labour Ward Department of Obstetrics & Gynecology, Nishtar Hospital Multan from 1.07.2017 to 31.12.2017. Methodology: Ninety five patients having positive pregnancy tests and uterine cavity with no intrauterine gestational sac on ultrasound were included. Clinical presentation like amenorrhea, vaginal bleeding, acute abdomen, shock or asymptomatic were assessed. Results: Amenorrhea observed in 73(76.8%) women, vaginal bleeding was seen in 32 (33.7%) women, 88 (92.6%) patients presented with acute abdomen and vitals instability was seen in 8 (8.4%) patients and 6(6.3%) patients were without symptoms. Conclusion: The two most common clinical presentations in patients included in study were amenorrhea and acute abdomen. Thorough evaluation of the patients with sub-acute or chronic presentation should be adopted to diagnose the cases of ectopic pregnancy. Key words: Ectopic pregnancy; Clinical presentation; Variations