Ectopic pregnancy in previous Caesarean section scar

We report two cases of Caesarean scar pregnancies that were managed surgically. The first case was a 33-year-old woman who presented at 21 weeks of gestation with lower abdominal pain. An exploratory laparotomy was performed as she was hypotensive and had a drastic drop in haemoglobin level. Intraoperatively, a ruptured scar ectopic pregnancy with placenta percreta was found. A hysterectomy was performed in view of uncontrolled haemorrhage. The second case was a 30-year-old woman who presented with irregular per vaginal spotting without abdominal pain. Ultrasonography revealed a gestational sac at a previous Caesarean scar, with interval increase in size and development of a yolk sac. On laparoscopy, the diagnosis of scar pregnancy was confirmed, and the gestational sac and surrounding myometrium were excised. Our case report shows that early diagnosis of scar pregnancy is important, as timely intervention can prevent life-threatening complications and preserve fertility.     

Primary omental pregnancy

Omental pregnancy is a rare form of ectopic pregnancy, and can be seen primarily or secondary to a tubal pregnancy. A 25-year-old woman presented with abdominal distention with pain and anemia without vaginal bleeding. After a provisional diagnosis of ruptured ectopic pregnancy, laparotomy was performed. On surgical exploration, the bilateral tubes and ovaries were intact, however, an omental pregnancy was detected as the cause of hemoperitoneum. Partial omentectomy was performed. Although most cases are secondary, presented here is an additional case of primary omental pregnancy at 12 weeks according to Studdiford's criteria. Histological evidence of neovascularization into the supporting tissue confirmed our diagnosis. A primary omental pregnancy should always be considered as a possible explanation for severe hemoperitoneum in ectopic pregnancies presenting with acute abdomen, and with intact adnexes on surgical exploration.     

Advanced abdominal pregnancy: a case report of good maternal and perinatal outcome

Advanced abdominal pregnancy is understood to mean any extra-uterine pregnancy found within the peritoneal cavity that is greater than 20 weeks gestation. Its management is one of laparotomy with varying complications including poor perinatal outcome and increased maternal morbidity and mortality. There is no accepted consensus for the complete removal of the placenta at laparotomy. This paper reports the management of a unique case of advanced abdominal pregnancy that was diagnosed by ultrasound at 20 weeks gestation and treated conservatively until delivery of a viable female neonate at 33 weeks and 4 days by elective laparotomy. At the time of laparotomy, the placenta was removed completely with good maternal outcome. This, to the best of our knowledge, is the first case in the West Indian literature documenting complete removal of the placenta at the time of laparotomy with good maternal outcome.     

宫角妊娠2例

宫角妊娠指受精卵种植在子宫与输卵管开口交界处的子宫角部,为罕见的异位妊娠,可引起各种并发症,最常见的是流产、子宫破裂和胎盘残留。由于宫角血供丰富,一旦发生子宫破裂常致大量出血,可能危及产妇生命。因其位置的特殊性,如果早孕期漏诊,至妊娠后期也极易漏诊、误诊。本文回顾2例孕晚期宫角妊娠病例,并结合文献资料,探讨该疾病的诊断、治疗方法。     

Uterus didelphys with fibroid uterus and ovarian cyst--rare Muellerian malformation

Persistent Muellerian duct syndrome is a very rare anomaly. A woman of 46-year-old was admitted with the history of lower abdominal pain, bleeding per vaginum and irregular menstrual cycles for last 6 months. An irregular non-tender mass of 16 x 10cm in size was palpable in suprapubic region. Per vaginal examination revealed two cervices and an incomplete vaginal septum. Ultrasound abdomen showed one uterus with endometrial cavity clearly delineated with a fibroid and an ovarian cyst in the left lumbar region. On laparotomy, 2 uterii along with a fibroid from the anterior wall of left uterus and a left ovarian cyst was seen. Patient had undergone total abdominal hysterectomy and adnexa removal. The specimen showed florid adenomyosis with leiomyoma of fibroid.     

Ovarian multifoetal pregnancy

A 24 years Muslim lady was admitted to SSKM Hospital with the complaint of pain lower abdomen, more on left side with ultrasonography diagnosis of alive foetuses in a twin pregnancy of 19-20 weeks of gestational age. On the very next day, foetal heart sound disappeared with complaint of no foetal movement. Doppler study and USG confirmed death of the foetuses. Laparotomy performed 3 weeks after foetal death revealed soft bulky uterus of about 10 weeks gestational age. Left fallopian tube was found highly stretched over the upper aspect of gestational mass and left overy could not be traced. Total hysterectomy with removal of the mass and left tube with preservation of right ovary and tube was carried out. On pathological examination, the uterus and the gestational mass were found empty and separated from the mass. There were two gestational sacs with two separate placentae, cords and foetuses of 20 weeks maturity. Microscopic examination showed infiltration of ovarian stroma by intermediate trophoblast indicating ovarian nidation.     

Pregnancy luteoma presenting as ovarian torsion with rupture and intra-abdominal bleeding

We report a case of pregnancy luteoma, which had undergone torsion in a 33-year-old Indian woman, who presented with severe abdominal pain and decreasing haemoglobin levels at 33 weeks gestation. Ultrasonography showed a right adnexal mass, probably ovarian in origin, with suspicious intratumoral bleed. The pain was treated symptomatically, and the symptoms improved. A successful induction of labour was then performed at 36 weeks gestation. The pain recurred almost immediately after the delivery, and she experienced another intra-abdominal bleed. A diagnostic laparotomy and a right salpingo-oophorectomy were performed, and the diagnosis of luteoma was made based on histology. We discuss the clinical presentation of this unusual tumour, though often asymptomatic, can rarely present with severe abdominal pain from complications like torsion with rupture, leading to massive intra-abdominal bleeding. We also discuss the possible radiological investigations which can be done during pregnancy.     

子宫动脉化疗栓塞后妊娠囊刮除治疗宫颈/峡部妊娠的临床价值

目的探讨经肱动脉入路行双侧子宫动脉化疗栓塞对宫颈妊娠和子宫峡部妊娠的治疗价值。方法选择本院2009年7月～2012年1月收治并确诊的宫颈妊娠、子宫峡部妊娠、切口妊娠患者116例,术前测定患者血β-HCG水平,检查孕囊大小,行肱动脉穿刺双侧子宫动脉化疗栓塞后,立即行妊娠囊刮除术,即刻终止妊娠。术后监测血β-HCG值、B超检查宫颈变化,观察术后副反应、并发症,随访月经以及再妊娠情况。结果本组患者全部一次治疗成功,均保留了生育功能,术后阴道出血明显减少或停止,无一例出现大出血,血β-HCG水平显著下降,出院后随访,患者宫颈形态、月经周期于治疗后3个月内恢复正常,血β-HCG水平恢复正常时间为（3.5±1.2）周。结论经肱动脉入路行双侧子宫动脉化疗栓塞治疗后妊娠囊刮除治疗宫颈/峡部妊娠,安全可行,可保留子宫和生育功能,有较高的应用价值。     

Clinics in diagnostic imaging (92)

A 43-year-old woman presented with a 10-day history of lower abdominal pain and two days of vaginal bleeding. Ultrasonography showed a sac-like structure within the endocervical canal. The structure had a thick echogenic rim. No foetal heartbeat was seen. Intramuscular methotrexate was given and evacuation of the uterus yielded a small amount of tissue which was revealed histologically as products of conception, confirming the diagnosis of a cervical ectopic pregnancy. The clinical and imaging features of cervical ectopic pregnancy are highlighted.     

Myomectomy during second trimester pregnancy: a case report

The prevalence of leiomyoma during pregnancy is reported as approximately 2%. Although during pregnancy leiomyomas usually remain asymptomatic, they may complicate its course. The management of leiomyoma during pregnancy is medical, but in certain circumstances surgical intervention and myomectomy may be required. This 28-year-old primigravida presented with progressively worsening lower abdominal pain at 14 weeks gestational age. Ultrasonography demonstrated a large fundally sited multi lobulated fibroid extending up to the right hypochondrium. There was an intrauterine gestation compatible with her menstrual dates. Laparotomy confirmed a large leiomyoma showing benign degenerative changes. The operative procedure was successful, and the pregnancy progressed normally. She was admitted at 34 weeks gestation with a diagnosis of antepartum haemorrhage. She was managed conservatively in the ward until 37 completed weeks gestation when she had an elective caesarean section and delivered of a live male neonate with a birth weight of 2.7 kg. She had type III placenta praevia.     

特殊部位异位妊娠超声检查的特点分析

目的分析特殊部位异位妊娠超声检查的特点。方法回顾性分析本院2018年1月至2019年12月经临床手术证实的80例特殊部位异位妊娠患者的临床资料,所有患者均给予超声(经腹联合经阴道)诊断,以手术结果为标准,分析超声诊断对特殊部位异位妊娠诊断与手术结果的一致性及特殊部位异位妊娠的超声影像特征。结果经Kappa检测,超声诊断不同类型特殊部位异位妊娠与手术诊断结果的一致性较好(Kappa=0.810,P=0.000),超声诊断的特殊部位异位妊娠的误诊率为13.75%;瘢痕妊娠孕囊型的超声特点:孕囊完全或部分着床于子宫瘢痕位置,血流信号可见环状或条索状滋养血流,局部肌层存在缺损或肌层较薄;混合型包块的超声特点:瘢痕位置可见不均匀回声,浆膜层局部外凸或不完整,包块周边可见低速低阻血流信号。输卵管间质部的超声特点:宫腔内未见孕囊,子宫旁一侧可见孕囊或不均匀包块,孕囊周边肌层厚度<5 mm,孕囊周边可见环状高回声,呈间质线样征,周边肌层较薄弱或有缺损。宫角妊娠的超声特点:孕囊位于一侧宫角且宫角增大膨出,孕囊或包块与宫腔内膜互通,且周边存在完整肌层包绕。卵巢妊娠的超声特点:宫腔内未见孕囊,孕囊型一侧卵巢内可见孕囊、卵黄囊、胚芽及胎心管搏动,囊壁较厚且绒毛膜光环明显,包块型可见混合型回声,周边卵巢实质内可见卵泡或黄体,包块内可见条状、点状血流信号。腹腔妊娠:原发性腹腔妊娠超声特点,子宫大小、形态、回声正常,宫旁一侧可见孕囊样回声,周边呈增强厚壁回声,可探及胚芽且可见心管搏动,甚至可探及不均匀的胎盘回声,内散在斑点状强回声,腹腔可探及腹腔积液,内见条索状分隔,且胎盘周边可见丰富蓝红色血流包绕;继发性腹腔妊娠超声特点,子宫增大、子宫内膜增厚且呈不均匀回声,可见腹腔积液,大网膜上可探及羊膜囊、内见胎儿、胎心搏动、胎盘组织,羊膜囊与膀胱间未见子宫肌壁层。结论不同类型特殊部位异位妊娠的超声特点存在较大差异,但仍存在误诊情况,故临床上应充分了解患者病史,扩大扫查范围,以提高临床诊断的准确性。     

Right ectopic gestation following in vitro fertilisation: case report

The management of ectopic gestation has in recent years transformed from the normally accepted laparotomy to the laparoscopic approach. The objective of this case report is to describe a rare occurrence of an ectopic gestation following in vitro fertilisation procedure. A 35-year-old para 0 + 0, presented with lower abdominal pain and per vaginal bleeding six weeks after an in vitro fertilisation was done in South Africa. The patient was admitted with severe lower abdominal pain and per vaginal bleeding at six weeks gestation following an in vitro fertilisation procedure. She had undergone an "evacuation" one-week prior to this episode due to an initial diagnosis of an incomplete abortion. No chorionic villi were reported on histology. The repeat serum BhCG was 777 mimicro/l and at laparoscopy a right unruptured ampullary ectopic gestation (4 cms in size) was evident. A right linear salpingostomy was subsequently performed laparoscopically. Histology confirmed the presence of tubal chorionic villi. The laparoscopic management of ectopic pregnancies is now regarded as the gold standard in many centres in the world. In this patient the ectopic pregnancy resulted following an intra-uterine zygote transfer, and was managed successfully.     

Primary hepatic pregnancy

A case of a 28 weeks primary hepatic pregnancy in a 25 year old female is reported. A live male fetus weighing 1300 g was delivered after laparotomy and the placenta was left intact. The uterus was of 8 weeks size with patent tubes. The patient made an uneventful recovery.     

依沙吖啶联合米非司酮终止瘢痕子宫中期妊娠的临床研究

目的研究依沙吖啶联合米非司酮终止瘢痕子宫中期妊娠的临床效果。方法选取2009年1月～2012年1月在我院自愿要求终止中期妊娠（孕13-27周）、合并瘢痕子宫者100例,将其随机分为观察组和对照组各50例。对照组给予依沙吖啶,观察组在对照组基础上同时联合米非司酮,比较两组的引产效果。结果两组引产均在注药后48h内分娩,其中观察组的引产成功率为100％,对照组引产成功率为96．0％,且两组均无宫颈裂伤、子宫破裂等并发症发生。与对照组比较,观察组用药后宫缩发动时间快、产时出血量少、胎盘和胎膜残留以及胎盘粘连发生率低,差异有统计学意义（P〈0．05或P〈0．01）。结论依沙吖啶联合米非司酮终止瘢痕子宫中期妊娠疗效确切．值得推广和应用。     

Unexpected placenta accreta spectrum after the use of assisted reproductive technology in women with adenomyomectomy

Placenta accreta spectrum (PAS) is a rare complication that can lead to life-threatening postpartum hemorrhage. PAS can sometimes occur unexpectedly, without placenta previa; such cases can lead to higher maternal mortality and morbidity than expected cases. Here, the authors report a case of unexpected PAS caused by assisted reproductive technology (ART) in a woman with adenomyosis. The patient was a 37-year-old Japanese primipara woman who presented to our hospital at 11 weeks gestation, later returning to her parents’ house to give birth. The woman had adenomyosis and underwent adenomyomectomy, which was followed by an ART pregnancy. The patient was admitted to our hospital because of a life-threatening preterm birth, with a short cervix and no evidence of placenta previa. Despite strict perinatal management, preterm rupture of the membrane (PROM) occurred. During laparotomy, the small intestine, rectum, and both right and left ovaries were clumped together and severely adhered to the surface of the uterus. After delivery, manual partial removal of the placenta was performed, resulting in heavy bleeding from the implantation site, which was diagnosed as an unexpected PAS. Following several uterine compression efforts, we successfully preserved the uterus.     

少见部位异位妊娠16例临床分析

目的: 探讨少见部位异位妊娠的临床特征、早期诊断及处理。方法: 回顾性分析16例少见部位异位妊娠的临床资料。结果: 少见部位异位妊娠主要包括子宫角妊娠、输卵管间质部妊娠、卵巢妊娠、子宫颈妊娠、腹腔妊娠、残角子宫妊娠和宫内宫外同时妊娠。其发生率占同期异位妊娠的4.90%,主要症状以腹痛、停经、阴道流血为主。所有患者均经手术治疗,且预后良好。结论: 少见部位异位妊娠是严重危及妇女健康的急腹症,早期临床表现不典型,易误诊和漏诊。一旦确诊,应立即手术。     

Late-diagnosed cesarean scar pregnancy resulting in unexpected placenta accreta spectrum necessitating hysterectomy

Cesarean scar pregnancy (CSP) is a rare complication involving the implantation of the gestational sac in a cesarean delivery scar. The authors report a case of unexpected placenta accreta spectrum (PAS) caused by late diagnosed CSP, necessitating emergent hysterectomy. A 28-year-old Japanese woman with two previous cesarean deliveries presented to our hospital at 11 weeks of gestation with abnormal transvaginal ultrasound findings obtained at another hospital;however, transabdominal ultrasound revealed that the fetus was already present in the uterine cavity at this time. At 28 weeks, there was no evidence of placenta previa. The woman developed preeclampsia at 29 weeks, and a cesarean section was conducted. Intraoperative findings confirmed PAS, and hysterectomy was conducted immediately.     

孕囊内注射MTX联合宫腔镜治疗子宫瘢痕妊娠62例临床分析

目的探讨孕囊内注射MTX联合宫腔镜治疗子宫瘢痕妊娠的临床价值。方法回顾性分析2006年1月～2012年12月我院62例孕囊内注射MTX联合官腔镜治疗的子宫瘢痕妊娠的临床资料。结果62例患者均为1型子宫瘢痕妊娠,彩超均为活胚。囊内注射MTX前血B—HCG（9590±1230）mlU／mL,注射后4d血β-HCG下降（87．5±11．8）％,1周血β-HCG下降（93．5±12．3）％。孕囊死亡平均时间为3～8d。官腔镜术中无子宫穿孔、子宫破裂、大出血发生。结论孕囊内注射MTX联合官腔镜治疗孕囊向宫内生长、活胚的I型子宫瘢痕妊娠具有疗效好、治疗周期短、血B—HCG恢复快、创伤小、出血少的特点,是安全、有效的治疗方法。     

Intussusception complicating triplet pregnancy

Intestinal obstruction complicating pregnancy is one of the surgical emergencies that may be associated with high incidence of morbidity and mortality for both mother and fetus. Our case is a case of triplets' pregnancy at 25 weeks gestation complicated by jejunal intussusception. The patient was admitted to our hospital with acute abdominal pain and diagnosis of intussusception was made. The patient had an urgent laparotomy with excision of a gangrenous loop of small bowel and primary re-anastomosis was carried out. Post operatively she developed wound dehiscence, which was repaired, and an emergency caesarean section was made on the same setting.     

经阴道彩色多普勒超声对切口妊娠的诊断效能及超声分型的临床价值分析

目的分析经阴道彩色多普勒超声对切口妊娠的诊断效能及其对切口妊娠分型的临床价值。方法选取2017年2月～2019年2月娄底市中心医院375例临床疑似切口妊娠的病例作为研究对象,对患者进行彩色多普勒超声检查,重点观察孕囊或异常回声与子宫前壁下段切口的关系及周边和内部血流情况,诊断是否为切口妊娠,对阳性者进行超声分型,并追踪患者的临床处理及预后。结果 375例患者中,150例为切口妊娠,225例为非切口妊娠,147例经超声诊断并经病理证实为切口妊娠,其中绒毛型85例(57.823%),混合型39例(26.531%),孕囊型17例(11.565%),发育不良型6例(4.082%),漏诊3例;经宫腔镜治疗143例,4例行开腹手术患者超声分型均为孕囊型,继续妊娠3例均为绒毛型(Ia型)。经阴道彩色多普勒超声诊断切口妊娠敏感度为98.000%,特异度为97.778%,误诊率为2.273%,漏诊率为2.000%。结论经阴道彩色多普勒超声对切口妊娠的诊断效能高,对切口妊娠分型具有一定的临床价值。