Primary peritoneal pregnancy implanted on the uterosacral ligament: a case report

Peritoneal pregnancies are classified as primary and secondary. Primary implantation on the peritoneum is extremely rare in extrauterine pregnancy and is a potentially life-threatening variation of ectopic pregnancy within the peritoneal cavity, representing a grave risk to maternal health. Secondary abdominal pregnancies are by far the most common and result from tubal abortion or rupture, or less often, after uterine rupture with subsequent implantation within abdomen. Early diagnosis and appropriate surgical management, regardless of stage of gestation, appear to be important in achieving good results. We report a case of primary peritoneal pregnancy in a 28-year-old woman, who had severe lower abdominal pain one day before laparotomy for a preoperative diagnosis of ectopic pregnancy. The conceptus was implanted on the left uterosacral ligament. A fresh embryo of approximately 8 weeks' gestation was found in the conceptus.     

Placenta percreta causing rupture of an unscarred uterus at the end of the first trimester of pregnancy: case report

Reports on placenta percreta in early pregnancy leading to a spontaneous rupture of the uterus are rare. We report a case of this potentially life-threatening complication in the 14th week of pregnancy in an otherwise healthy woman who underwent a manual extraction of the placenta during a previous delivery but who had no history of severe pathology that could have potentially resulted in uterine damage. The occurrence of severe abdominal pain and the presence of a large quantity of free fluid in the abdomen necessitated an emergency laparotomy, revealing a haemoperitoneum due to rupture of the uterus, which was followed by a hysterectomy. This case demonstrates that in patients with a history of placenta accreta and subsequent manual extraction of the placenta, a close investigation of the uterine wall and placentation should be performed in the first trimester in order to anticipate a placenta percreta.     

Uterine dehiscence in a nullipara,diagnosed by MRI,following use of unipolar electrocautery during laparoscopic myomectomy: Case report

Uterine scar dehiscence following laparoscopic myomectomy (LM) is a rare event. We present a case of an magnetic resonance imaging-diagnosed uterine dehiscence in a primigravid patient at 29 weeks gestation, following a laparoscopic subserosal myomectomy, performed using unipolar electrocoagulation. Pregnant patients with a history of prior surgery where unipolar electrocoagulation is used on the uterus should be closely followed throughout pregnancy and uterine dehiscence or rupture should be part of the differential diagnosis when they present with abdominal pain.     

Hepatic and splenic rupture associated with severe preeclampsia: a case report

The splenic rupture is a rare complication of pregnancy and of the postpartum period. On the contrary, hepatic hemorrhage is a relatively common complication of pregnancy and it is usually associated with preeclampsia. In this work we report the case of a 37 year-old patient with a noncontrolled 35 week-pregnancy of simple, with severe preeclampsia. She presented abdominal pain, headache, hypertension and accented cutaneous-mucous paleness at the moment of admission to the hospital. During physical evaluation at admittance, the patient suddenly suffered a severe circulatory collapse and it was decided a surgical intervention. A segmental caesarean section was practiced, and during the abdominal exploration it was observed hemoperitoneous, a splenic rupture degree III and a hematoma in the anterolateral liver's wall. Total splenectomy and evacuation of the hepatic hematoma was performed. The splenic rupture and the hepatic subcapsular hematoma should be considered as a part of the differential diagnoses when a hemodynamic collapse occurs during labor in patients with severe preeclampsia. This work constitutes the first report in the Venezuelan literature of the association of splenic rupture, hepatic subcapsular hematoma and severe preeclampsia. An appropriate prenatal control, the knowledge of this association and an immediate therapeutic intervention are essential to assure the maternal-fetal survival.     

Laparoscopic myomectomy and subsequent pregnancy: results in 54 patients

The laparoscopic approach to myomectomy has raised questions about the risk of uterine rupture in patients who become pregnant following surgery. It has been suggested that the rupture outside labour in pregnancies following laparoscopic myomectomy can be due to the difficulty of suturing or to the presence of a haematoma or to the wide use of radio frequencies. In this paper we describe the pregnancy outcome of 54 patients submitted to laparoscopic myomectomy at our Institution and prospectively followed during subsequent pregnancies. A total of 202 patients underwent laparoscopic myomectomy. A total of 65 pregnancies occurred in 54 patients who became pregnant following surgery. Data were collected about complications of pregnancy, mode of delivery, gestational age at delivery and birthweight of the neonates. No cases of uterine rupture occurred. Twenty-one pregnancies followed an IVF procedure. Nine patients conceived twice and one three times. Four multiple pregnancies occurred. Eight pregnancies resulted in a first trimester miscarriage and another in an interstitial pregnancy requiring laparotomic removal of the cornual gestational sac. Of the remaining 56 pregnancies, 51 (91%) were uneventful. In two cases a cerclage was performed at 16 weeks. In two cases pregnancy-induced hypertension developed. Two pregnancies ended with a preterm labour (26-36 weeks). A Caesarean section was performed in 45 cases (54/57, 80%). In terms of the safety of laparoscopic myomectomy in patients who become pregnant following surgery, our results were encouraging. However, further studies are needed to provide reliable data on the risk factors and the true incidence of uterine rupture.     

Spontaneous rupture of splenic artery aneurysm in pregnancy: a case report

Splenic artery aneurysms (SAA) occur predominantly in women, and the majority of them are asymptomatic until rupture. Over half of those that rupture occur during pregnancy. Spontaneously ruptured SAA during pregnancy is always a life-threatening surgical entity for both the mother and the fetus. We report the case of a 29-year-old woman at 34 weeks' gestation with spontaneous rupture of SAA who underwent emergency exploratory laparotomy and splenectomy. This case illustrates the need to consider ruptured SAA as part of important differential diagnosis in haemodynamically unstable pregnant women.     

Evaluation of ectopic pregnancy by magnetic resonance imaging.

Patients (n = 37) suspected of ectopic pregnancy were prospectively evaluated with magnetic resonance (MR) imaging to assess the capability of MR imaging in the diagnosis of ectopic pregnancy. Five levels of confidence were defined: diagnostic, suspicious, equivocal, questionable, and negative. Tubal wall enhancement and presence of tubal haematoma or gestational sac-like structure were considered diagnostic findings. There were 21 diagnostic, two suspicious, eight equivocal, and six negative findings. MR findings were compared with the surgical findings in 18 patients. Surgical confirmation was obtained in 12 diagnostic, two suspicious, and four equivocal studies. Using the MR diagnostic criteria for tubal pregnancy, MR had 12 true positive, three true negative, three false negative, and no false positive results for the diagnosis of tubal pregnancy. Retrospective analysis of the signal intensity of haematoma and ascites was performed for these 18 surgically confirmed cases. The predominant signal intensity of tubal haematoma was an intermediate signal on T1-weighted image (WI) and a low signal on T2WI. Ascites showed signal intensity higher than that of urine on T1WI in 100% of 13 cases. In conclusion, MR imaging with use of intravenous contrast material allows a specific diagnosis of tubal pregnancy, recognizing tubal wall enhancement and fresh tubal haematoma.     

Fatal splenic rupture in a pregnant woman with hemoglobin C/beta-thalassemia and myeloid metaplasia

Splenic rupture with intraperitoneal hemorrhage is a fatal condition that is rarely encountered during the third trimester of pregnancy; its pathogenetic mechanisms and causes are largely unknown. We report a case of splenic rupture in a pregnant woman that caused the death of the mother and child. The patient was a carrier of double heterozygosis for hemoglobin C/beta-thalassemia. Spleen and liver enlargement due to extramedullary hematopoiesis was found at autopsy. Our data suggest that rare and hidden hematologic disorders should be considered as possible causes of splenic enlargement and rupture during pregnancy.     

Spontaneous uterine rupture in the first trimester: a case report

Uterine rupture is one of the most feared obstetric complications affecting the pregnant woman and fetus. Most of the cases have various risk factors and mainly occur during the second or third trimester. However, spontaneous uterine rupture during the first trimester is extremely rare. We experienced a case of spontaneous uterine rupture in a 36-yr-old multiparous woman without definite risk factors. The initial impression was a hemoperitoneum of an unknown origin with normal early pregnancy. Intensive surgical method would be needed for accurate diagnosis and immediate management in bad situation by hemoperitoneum even though a patient was early pregnancy.     

A large amniocele with protruded umbilical cord diagnosed by 3D ultrasound

An amniocele is a herniation of the amniotic sac through a uterine defect. Uterine rupture during pregnancy may develop as a result of a pre-existing injury, uterine anomaly, or unscarred uterus. A 30-year-old patient, with a history of 2 vaginal deliveries, presented an amniocele complicated by left fundal perforation and was evaluated with 3-dimensional ultrasound at 23 weeks. Because of worsening lower abdominal pain and vaginal bleeding, she underwent exploratory laparotomy. Herein, we report a uterine rupture with amniocele.     

13例宫角妊娠临床诊治分析

目的探讨宫角妊娠安全有效的诊治方案,为临床提供可靠的依据。方法对我院13例宫角妊娠做一回顾性分析。结果13例中B超提示宫角妊娠的7例,一侧宫角部不均质包块的2例;中期妊娠死胎入院引产的2例,经常规引产失败后行剖宫取胎术,术中均证实为宫角妊娠;1例死胎因腹腔大出血行剖腹探查术,术中证实为宫角妊娠破裂;1例因晚期流产后胎盘滞留入院,B超及手术后证实为宫角妊娠,行子宫切除术。结论宫角妊娠可引起各种并发症,常见的是流产、子宫破裂和胎盘滞留。根据宫角妊娠发生的类型选择个体化的治疗方法。     

Spontaneous bilateral cornual uterine dehiscence early in the second trimester after bilateral laparoscopic salpingectomy and in-vitro fertilization: case report.

A bilateral cornual uterine dehiscence is reported, which occurred 14 weeks after in-vitro fertilization (IVF) in a patient having a medical history of previous bilateral salpingectomy via laparoscopy. Uterine rupture is a rare obstetric complication usually occurring during the third trimester of pregnancy within a uterus which has previously undergone an operation. Ectopic pregnancy is a well known complication of IVF. Post-salpingectomy cornual localization with rupture has also been published. Possible causes are discussed and the attention of the counselling physician is directed to the necessary awareness of such a complication in this high risk population. The reported case is an extreme rarity: a similar case has not been previously published in the literature.     

Dissecting aortic aneurysm in a horse

A case of dissecting aortic aneurysm in a 4-year-old male thoroughbred horse is reported. The horse had a history of inflammation in the right thigh and a fever 2 weeks before sudden death. At necropsy, aortic aneurysms were observed from the aortic valve to the aortic arch, spreading over a distance of 40 cm. An irregular rupture of the intima of the ascending aorta was located in the cardiac side of a ramification to the tunica branchiocephalicus communis. An intramural haematoma, apparent on the cut surface and in the pericardium, had caused cardiac tamponade and sudden death.     

Tubal curettage: a new conservative treatment for haemorrhagic interstitial pregnancies

Haemorrhagic interstitial pregnancies are commonly treated by cornual resection. This invasive procedure may increase the risk of uterine rupture in subsequent pregnancies. We report here a case of a haemorrhagic interstitial pregnancy, associated with a viable intrauterine pregnancy in a salpingectomized woman, which was treated successfully by curettage of the uterine cornu.     

Spontaneous splenic rupture: A rare presentation of dengue fever

Spontaneous rupture of the spleen with hemoperitoneum is a very rare, but serious manifestation of dengue fever (DF). We report a case of a young female who was presented with atraumatic abdominal pain, hypovolemic shock, anemia, ascites and hepatosplenomegaly with a recent history of a febrile illness. Subsequent investigations proved the presence of hemoperitoneum with spontaneous splenic rupture with seropositivity for DF. Early diagnosis and conservative management in this case resulted in a favorable outcome.     

Subdural haematoma with spontaneous resolution--rare manifestation of idiopathic thrombocytopenic purpura

Spontaneous intracranial haemorrhage presenting as subdural haematoma is an extremely rare presentation in adults due to idiopathic thrombocytopenic purpura. There are only five such case reports available in the literature and four had surgical evacuation of haematoma, while only one had spontaneous resolution. We report the case of a middle aged female who presented with bilateral papilloedema and later diagnosed to have subdural haematoma as a complication of idiopathic thrombocytopenic purpura, which had a spontaneous resolution.     

Spontaneous splenic rupture in atypical (Philadelphia chromosome negative) chronic myeloid leukaemia following blastic crisis

Philadelphia chromosome negative and bcr/abl negative chronic myeloid leukaemia (CML) is an uncommon atypical CML. We describe a patient with this disorder who experienced an acute blastic transformation that resulted in rapid splenic enlargement and subsequent atraumatic splenic rupture. Clinically, spontaneous splenic rupture may be a difficult diagnosis to make and this case highlights the importance of considering atraumatic splenic rupture as a cause for unexplained abdominal pain in a patient with a haematological malignancy.     

Ultrasonography in acute pelvic pain

Acute pelvic pain may be the manifestation of various gynecologic and non-gynecologic disorders from less alarming rupture of the follicular cyst to life threatening conditions such as rupture of ectopic pregnancy or perforation of inflamed appendix. In order to construct an algorithm for differential diagnosis we divide acute pelvic pain into gynecologic and non-gynecologic etiology, which is than subdivided into gastrointestinal and urinary causes. Appendicitis is the most common surgical emergency and should always be considered in differential diagnosis if appendix has not been removed. Apart of clinical examination and laboratory tests, an ultrasound examination is sensitive up to 90% and specific up to 95% if graded compression technique is used. Still it is user-depended and requires considerable experience in order to perform it reliably. Meckel's diverticulitis, acute terminal ileitis, mesenteric lymphadenitis and functional bowel disease are conditions that should be differentiated from other causes of low abdominal pain by clinical presentation, laboratory and imaging tests. Dilatation of renal pelvis and ureter are typical signs of obstructive uropathy and may be efficiently detected by ultrasound. Additional thinning of renal parenchyma suggests long-term obstructive uropathy. Ruptured ectopic pregnancy, salpingitis and hemorrhagic ovarian cysts are three most commonly diagnosed gynecologic conditions presenting as an acute abdomen. Degenerating leiomyomas and adnexal torsion occur less frequently. For better systematization, gynecologic causes of acute pelvic pain could be divided into conditions with negative pregnancy test and conditions with positive pregnancy test. Pelvic inflammatory disease may be ultrasonically presented with numerous signs such as thickening of the tubal wall, incomplete septa within the dilated tube, demonstration of hyperechoic mural nodules, free fluid in the "cul-de-sac" etc. Color Doppler ultrasound contributes to more accurate diagnosis of this entity since it enables differentiation between acute and chronic stages based on analysis of the vascular resistance. Hemorrhagic ovarian cysts may be presented by variety of ultrasound findings since intracystic echoes depend upon the quality and quantity of the blood clots. Color Doppler investigation demonstrates moderate to low vascular resistance typical of luteal flow. Leiomyomas undergoing degenerative changes are another cause of acute pelvic pain commonly present in patients of reproductive age. Color flow detects regularly separated vessels at the periphery of the leiomyoma, which exhibit moderate vascular resistance. Although the classic symptom of endometriosis is chronic pelvic pain, in some patients acute pelvic pain does occur. Most of these patients demonstrate an endometrioma or "chocolate" cyst containing diffuse carpet-like echoes. Sometimes, solid components may indicate even ovarian malignancy, but if color Doppler ultrasound is applied it is less likely to obtain false positive results. One should be aware that pericystic and/or hillar type of ovarian endometrioma vascularization facilitate correct recognition of this entity. Pelvic congestion syndrome is another condition that can cause an attack of acute pelvic pain. It is usually consequence of dilatation of venous plexuses, arteries or both systems. By switching color Doppler gynecologist can differentiate pelvic congestion syndrome from multilocular cysts, pelvic inflammatory disease or adenomyosis. Ovarian vein thrombosis is a potentially fatal disorder occurring most often in the early postpartal period. Hypercoagulability, infection and stasis are main etiologic factors, and transvaginal color Doppler ultrasound is an excellent diagnostic tool to diagnose it. Acute pelvic pain may occur even in normal intrauterine pregnancy. This may be explained by hormonal changes, rapid growth of the uterus and increased blood flow. Ultrasound is mandatory for distinguishing normal intrauterine pregnancy from threatened or spontaneous abortion, ectopic pregnancy and other complications that may occur in patients with positive pregnancy test. Incomplete abortion is visualized as thickened and irregular endometrial echo with certain amount of intracavitary fluid. If applied, color Doppler ultrasound reveals low vascular resistance signals in richly perfused intracavitary area. Transvaginal sonography has high sensitivity and specificity in visualization of uterine and adnexal signs of ectopic pregnancy. Color Doppler examination may aid in detection of the peritrophoblastic flow. Furthermore, it facilitates detection of ectopic living embryo, tubal ring or unspecific adnexal tumor. Corpus luteum cysts and leiomyomas are another cause of pelvic pain during pregnancy, which can be correctly diagnosed by ultrasound. Detection of uterine dehiscence and rupture in patients with history of prior surgical intervention on uterine wall relies exclusively on correct ultrasound diagnosis. In patients with placental abruption sonographer detects hypoechoic complex representing either retroplacental hematoma, subchorionic hematoma or subamniotic hemorrhage. In closing, ultrasound has already become important and easily available tool which can efficiently recognize patients with possibly threatening conditions of different origins.     

Florid diffuse peritoneal deciduosis mimicking carcinomatosis in a primigravida patient: a case report and review of the literature

A case of a 27 year old G1P0 female with a dichorionic, diamniotic twin pregnancy presenting with premature rupture of membranes found to have omental caking and diffuse yellow-tan peritoneal nodules, clinically suspicious for carcinomatosis. The case work-up showed this to be an example of florid-diffuse peritoneal deciduosis mimicking carcinomatosis which has since resolved 4 months postpartum.     

Rupture of pregnancy in the communicating rudimentary uterine horn at 34 weeks

Pregnancy in the rudimentary horn is rare and represents a form of ectopic gestation. Despite advances in ultrasound, prenatal diagnosis remains elusive, with confirmatory diagnosis being made at laparotomy. Because of variable muscular constitution of the wall of the rudimentary horn, pregnancy can be accommodated until late in pregnancy, when rupture occurs manifesting commonly as acute abdomen with high risk of maternal mortality. The rudimentary horn may or may not communicate with the uterine cavity with majority of cases being non-communicating. We present a case of pregnancy in the communicating horn that was difficult to diagnose which ruptured at 34 weeks and a review of literature.