Management of patients with ectopic pregnancy with massive hemoperitoneum by laparoscopic surgery with intraoperative autologous blood transfusion

STUDY OBJECTIVE: To evaluate the feasibility and safety of surgical laparoscopy with intraoperative autologous blood transfusion for ectopic pregnancy with massive hemoperitoneum. DESIGN: Retrospective analysis (Canadian Task Force classification II-1). SETTING: Department of gynecology at a general hospital. PATIENTS: Seventeen consecutive patients with ectopic pregnancy with massive hemoperitoneum. INTERVENTION: Laparoscopic surgery with salvage device-based intraoperative autologous blood transfusion. MEASUREMENTS AND MAIN RESULTS: From January 2000 through June 2005, one hundred and twelve women with ectopic pregnancy (interstitial/cornual: 4; isthmic: 18; ampullary: 86; and ovarian: 4) were treated by laparoscopic surgery. Seventeen patients who demonstrated more than 501 g of intraabdominal bleeding were classified as having massive hemoperitoneum and retrospectively analyzed. Site of pregnancy in these 17 patients was interstitial/cornual: 3; isthmic: 5; ampullary: 7; and ovarian: 2. Except for two women with tubal abortion of ampullary pregnancy, all other patients had rupture at the pregnancy site. During laparoscopic surgery, blood pooled in the abdominal cavity was collected by an irrigation and aspiration procedure, and sent to an autologous blood-salvage device to make concentrated red blood cell solution. Processed blood was immediately transfused back to the patient through a leukocyte reduction filter. The mean amount of estimated intraabdominal bleeding, which was calculated by the difference between the volumes of aspirated and irrigated fluids, was 1362.1 +/- 491.4 g, and the mean volume of reinfused processed blood was 680.6 +/- 209.5 g. No patient received banked blood at any time. The degree of hemoperitoneum was well correlated with the shock index calculated by dividing the heart rate by systolic blood pressure at triage (r = 0.72; 95% CI 0.37-0.89; p = .001). In all cases of massive hemoperitoneum, there was no need for laparotomic conversion, and homologous blood transfusion was avoided. CONCLUSIONS: Even in women with ectopic pregnancy with massive hemoperitoneum, laparoscopic surgery can be safely conducted by experienced laparoscopists with intraoperative autologous blood transfusion if hemodynamic stability is achieved by perioperative management.     

Corpus luteum hemorrhage: rare complication of congenital and acquired coagulation abnormalities

Women taking anticoagulants or those with a clotting factor deficiency are at increased risk of corpus luteum rupture due to coagulation abnormalities and three such cases are described here. Case 1 was a 35-year-old woman with prosthetic mitral valve replacement who was on anticoagulant therapy, in whom hemoperitoneum secondary to ruptured corpus luteum was seen. Emergency laparotomy revealed 1.2 L of massive hemoperitoneum. Left salpingo-oophorectomy was performed. Case 2 was two episodes of hemoperitoneum from luteal cyst rupture in a young patient with the rare congenital factor X deficiency. This patient was managed conservatively with fresh frozen plasma and blood transfusion. This is the first case of congenital factor X deficiency manifested as luteal rupture to be managed conservatively. Case 3 was two episodes of hemoperitoneum from luteal cyst rupture in a patient with antiphospholipid antibody syndrome who was on oral anticoagulants. Laparotomy was done twice with left salpingo-oophorectomy in the first instance and partial excision of the right ovary in the second instance. Hemoperitoneum secondary to rupture of the corpus luteum should be considered in the differential diagnosis of acute abdominal pain in women with congenital and acquired coagulation deficiencies.     

Ovarian vascular accidents: a complication of anticoagulant therapy.

Ovarian vascular accidents are usually more severe when the patient is being kept on anticoagulant therapy following cardiac surgery or for other reasons. 4 cases of massive hemoperitoneum are reported. Rupture of the corpus luteum and corpus luteum cyst and an ovarian ectopic pregnancy were responsible for massive hemoperitoneum. All 4 patients survived and recovered.     

Laparoscopic surgery with intraoperative autologous blood transfusion in patients with heavy hemoperitoneum due to ectopic pregnancy

Patients with ectopic pregnancy complicated by heavy hemoperitoneum generally undergo immediate laparotomy, and homologous blood transfusion is sometimes started before the operation. Two women underwent laparoscopic surgery for heavy hemoperitoneum (2600 and 1900 ml) due to ectopic pregnancy. The aspirated blood was reinfused during operation through a leukocyte-reduction filter after lavage with an autologous blood-salvage transfusion apparatus.     

Ruptured Hemorrhagic Corpus Luteum Cyst in an Undescended Ovary: A Rare Cause of Acute Abdomen

BackgroundUndescended ovaries are typically detected during infertility evaluations and are frequently associated with uterine malformations. Ruptured hemorrhagic corpus luteum cyst of an undescended ovary is an unusual cause of acute abdomen in an adolescent.CaseA 15-year-old girl presented with right lower quadrant pain, nausea, and vomiting, and transabdominal sonography and magnetic resonance imaging of the pelvis showed a 10 cm × 5 cm sized cystic mass at the level of the pelvic brim, anterior to the psoas muscle suggestive of a retroperitoneal hemorrhagic cyst. At surgery, the uterus and left adnexa appeared normal, but the right ovary was not visible within the pelvic cavity, and the right pelvic retroperitoneum was distended. After opening the retroperitoneum and aspirating blood clots, the undescended ovary with a ruptured cyst was visualized within the retroperitoneum. Right ovarian wedge resection was performed and the right ovary was repositioned in the pelvic cavity.Summary and ConclusionRupture of a corpus luteum cyst in an undescended ovary should be included in the differential diagnosis of acute abdomen in adolescents.     

Laparoscopic management of consecutive ovarian pregnancy in a patient with infertility

The diagnosis of ovarian pregnancy is based on the improper rise of serum beta-hCG levels, sonographic findings of an empty uterus, highly characteristic ovarian formation with double hyperechogenic ring surrounding small hypoechogenic field, and the laparoscopic verification of Spiegelberg's criteria. We present a case of ovarian pregnancy in spontaneous cycle in 34-year-old woman following two unsuccessful IVF/ET procedures and ovarian pregnancy on contralateral side laparoscopically treated seven months ago, also achieved in non-stimulated, spontaneous cycle. On admission she had a serum hCG level of 596 mIU/mL on cycle day 46 and an empty uterus. Transvaginal sonography showed a 20 mm ring-like thick-walled hyperechogenic structure within the left ovary. The echogenic ring was surrounded by irregular, hypoechogenic structures suggestive of an ovarian pregnancy with periluteal hemorrhage and blood clots. The ruptured cystic ovarian pregnancy and the corpus luteum were removed by laparoscopy. During the procedure we have seen two clips on the right ovary placed laparoscopically to achieve hemostasis after rupture of the ovarian pregnancy seven months ago. Histopathology showed isolated chorionic villi within hemorrhagic areas in the vicinity of the corpus luteum.     

Early experience with isobaric laparoendoscopic single-site surgery using a wound retractor for the management of ectopic pregnancy

Objective

To report our initial experience with isobaric (gasless) transumbilical laparoendoscopic single-site (LESS) surgery using a wound retractor for the management of ectopic pregnancy.

Study design

Twelve consecutive cases of ectopic pregnancy were managed by isobaric LESS surgery with the subcutaneous abdominal wall-lift method. In each case, a wound retractor was used as a transumbilical working port with insertion into the peritoneal cavity through a 2.5-cm vertical umbilical incision. Subsequent surgical procedures were performed with multiple conventional laparoscopic instruments through single umbilical port.

Results

All cases of ectopic pregnancy were successfully managed by isobaric LESS surgery. Procedures included salpingectomy in eight cases of ampullary pregnancy and two cases of isthmic pregnancy, salpingectomy and local methotrexate injection in one case of isthmic pregnancy, and salpingo-oophorectomy for one case of ovarian pregnancy. Neither extraumbilical incisions nor conversion to laparotomy was required. In a case of ruptured ampullary pregnancy with massive hemoperitoneum, intraoperative autologous blood salvage and donation avoided the need for the transfusion of bank blood. Although postsurgical umbilical seroma was noted in one case and systemic methotrexate administration was required for persistent ectopic pregnancy in one case of isthmic pregnancy respectively, there were no major surgical complications in this series. The technique yielded excellent cosmetic results with minimum postoperative scar concealed within umbilicus. Retrospective comparison of surgical parameters including surgical duration, estimated blood loss, frequency of postoperative analgesic use, time of bowel recanalization, postoperative inflammatory response and postoperative hospital stay did not show any significant differences between isobaric LESS surgery group and conventional isobaric multiport laparoscopic surgery group.

Conclusions

Based on the satisfactory outcome achieved in these initial 12 cases of ectopic pregnancy treated by isobaric LESS surgery, the wound retraction system combined with the subcutaneous abdominal wall-lift method appears to contribute favorably to LESS surgery for the management of ectopic pregnancy because the device permits free circumferential access and retraction during procedures without the closed condition required during pneumoperitoneum.     

Recurrent massive hemoperitoneum due to ovulation as a clinical sign in congenital afibrinogenemia

Massive hemoperitoneum due to ovulation is a rare but serious and life-threatening complication for women with coagulation disorders, and may lead to surgical interventions and even oophorectomy. Congenital afibrinogenemia is an uncommon coagulation disorder usually discovered during childhood. Intraabdominal bleeding due to ovulation is very rare in these patients and only a few cases of corpus luteum rupture and hemoperitoneum in afibrinogenemic patients have been described. In all women, the diagnosis was known since childhood. We report on a 24-year-old woman with congenital afibrinogenemia with recurrent massive intraabdominal bleeding due to ovulation as the presenting clinical sign. Exploratory laparotomy and excision of the ruptured follicle was performed at the first bleeding episode; the second episode was managed with fresh frozen plasma and blood transfusions. Conservative management is crucial for these patients. If surgery cannot be avoided, a conservative surgical approach should be chosen to preserve ovarian function.     

Intraoperative Autologous Blood Transfusion of Peritoneal Blood During Laparotomy for Ectopic Pregnancy: Prospective Study

Objective

The purpose of this study was to evaluate the efficacy and safety of intraoperative autologous blood transfusion during laparotomy for hemoperitoneum in ectopic pregnancy and also safety of homologous blood transfusion along with autologous blood transfusion.

Method

Fresh blood, from peritoneal cavity, was collected for autotransfusion in sterile dish, filtered through eight layers of sterile gauze pieces, and collected in a sterile bowl. The collected blood was transferred into blood infusion bag containing citrate phosphate dextrose adenine solution in the proportion of five parts of blood to one part of citrate solution.

Results

Mean volume of autologous blood transfused in patients without homologous transfusion was 573 ± 328. Mean preoperative hemoglobin was 4.95 ± 1.5, and postoperative hemoglobin was 6.85 ± 1.3. Hence, rise in hemoglobin was 1.9 g%. Autologous blood volume transfused in 29 patients (who required homologous blood transfusion) was 488 ± 216. Preoperative hemoglobin was 4.35 ± 1.94. The result was compared with other studies.

Conclusion

Intraoperative autologous blood transfusion enabled the performance of laparotomy in hemodynamically unstable ectopic pregnancy patients without availability of homologous blood transfusion. Homologous blood transfusion is compatible with autologous blood transfusion.     

Comparison of laparoscopy and laparotomy in managing hemodynamically stable patients with ruptured corpus luteum with hemoperitoneum

STUDY OBJECTIVE: To compare differences between laparoscopy and laparotomy in managing women ruptured corpus luteum with hemoperitoneum. DESIGN: Three-year, prospective, nonrandomized study (Canadian Task Force classification II-2). SETTING: University-affiliated regional hospital. PATIENTS: Sixty hemodynamically stable women. INTERVENTION: Laparoscopic surgery (30 women) and laparotomy (30). MEASUREMENTS AND MAIN RESULTS: Laparoscopic surgery had significant advantages over laparotomy, including shorter hospital stay (55.33 +/- 7.67 vs 97.77 +/- 14.45 hrs, p < 0.001) without increased adverse events. Laparoscopic surgery also showed trends of shorter operating time, improved wound care, and less postoperative pain. CONCLUSION: Laparoscopy surgery for diagnosis and treatment of women with ruptured hemorrhagic corpus luteum appears superior to laparotomy. We suggest that surgeons try laparoscopy first as a diagnostic and probably therapeutic procedure.     

黄体破裂——一种不容忽视的急腹症

目的 探讨黄体破裂的诊断与处理。方法 我院1990年7月～1999年7月共收治黄体破裂患者62例,分析患者的年龄、婚育史、临床症状、诊断、手术方式、术中所见、出血量及病理检查结果。结果 62例患者中,25例行保守治疗后痊愈,37例行手术治疗,包括卵巢部分切除术,附件切除术,或腹腔镜下行卵巢部分切除术并电凝止血。手术治疗患者中.术中腹腔内出血情况:出血量大于500 ml者27例(73.％),其中出血500～1000 ml者14例(37.8％),出血大于1000 ml者13例(35.1％)。结论 黄体破裂仍可引起大量的腹腔内出血,危及患者生命安全,且与异位妊娠难以鉴别,故仍需要及时的手术干预。     

Hemorrhagic corpus luteum in two phases]

In a young woman, hemiperitoin is nearly always the result of the rupture of an ectopic pregnancy. The authors report the case of the rupture of a cyst of a corpus luteum and they review the literature in order to identify the semiological signs and it highlight the difficulty of reaching a diagnosis by non-invasive methods. The treatment remains surgery, involving ablation of the corpus luteum.     

Ruptured corpus luteum with hemoperitoneum: a study of 173 surgical cases

Ovarian hemorrhage from the corpus luteum of menstruation or pregnancy can be a life-threatening surgical condition which occurs at all stages of a woman's reproductive life. A corpus luteum cyst predisposes to rupture. There may be a delay of menses. Pregnancy increases the risk of rupture, and there is an increased risk of abortion and ectopic pregnancy. Most ruptures occur in the right ovary and can be misdiagnosed as appendicitis. Culdocentesis is positive for hemoperitoneum, and if the hematocrit is over 12%, surgical intervention is indicated for hemostasis. A tissue diagnosis should be made by cystectomy, luteectomy, or wedge excision.     

Oxidized cellulose (Surgicel) granuloma mimicking a primary ovarian tumor.

A 37-year-old woman presented with left lower quadrant pain and vaginal spotting 1 month after hysterectomy and right salpingo-oophorectomy, which were performed for hemoperitoneum related to a ruptured corpus luteum. An 8-cm left ovarian mass was removed that had a microcystic, mucoid sectioned surface. Histological examination revealed that the mass consisted of a massive foreign-body granulomatous reaction to oxidized cellulose (Surgicel). To our knowledge, this is only the second report of an ovarian Surgicel granuloma.     

Two episodes of hemoperitoneum from luteal cysts rupture in a patient with congenital factor X deficiency

The clinical manifestation of two episodes of hemoperitoneum from ruptured corpus luteum cysts, during the luteal phase of the cycle in a young patient with the rare congenital factor X deficiency, is reported for the first time in literature. The correct diagnosis of the underlying disorder, the gynecological management and the regular follow-up can minimize the risks of this potentially life-threatening hematological disorder.     

Early detection of ectopic pregnancy. Use of a sensitive urine pregnancy test and transvaginal ultrasonography

We performed a prospective study to evaluate the reliability of a rapid monoclonal antibody urine pregnancy test with a sensitivity limit of 20 mIU/mL combined with transvaginal ultrasonography in the early diagnosis of ectopic pregnancy in 116 women with subacute pelvic pain and a stable general condition. The diagnosis of tubal pregnancy was confirmed with laparoscopy in 100 of the 103 women with positive sensitive urine pregnancy tests and no intrauterine gestational sac at transvaginal ultrasonography. Laparoscopy revealed a hemorrhagic corpus luteum in four of the eight subjects with negative monoclonal antibody pregnancy tests and no intrauterine gestational sac, an ovarian cyst in three and a normal pelvis in one. Of the five women with a positive pregnancy test and an intrauterine gestational sac, two had a hemorrhagic corpus luteum, two a normal pelvis and one a tubal pregnancy at laparoscopy. The sensitivity of a monoclonal antibody urine pregnancy test and transvaginal ultrasonography combined for the diagnosis of ectopic pregnancy was 99%, and the specificity was 80%, with positive and negative predictive values of 97% and 92%, respectively.     

经阴道彩色多普勒能量超声对早期妊娠黄体的临床研究

目的:通过经阴道彩色多普勒能量超声(TV-CDPI)对早期妊娠黄体的检测,探讨其在早期妊娠诊断与鉴别诊断、评估预后的价值。方法:检测179例早期妊娠黄体形态、血供分布及血流动力学参数(RI和PSV),其中宫内早孕68例,异位妊娠35例,先兆流产44例,难免流产32例。结果:早期妊娠黄体二维声像图可分为4种类型,与不同妊娠组别有一定的相关性(P<0.01)。不同组别的妊娠黄体血供分布与血流动力学参数(RI、PSV)比较差异有非常显著性(P<0.01)。结论:TV-CDPI对早期妊娠黄体形态、血供分布及血流动力学参数的检测和观察,对早期妊娠的鉴别诊断、预后评价有重要的价值。     

Laparoscopy versus laparotomy in the management of ectopic pregnancy with massive hemoperitoneum

Objective

To compare the safety and feasibility of operative laparoscopy versus laparotomy in women with ruptured ectopic pregnancy and massive hemoperitoneum.

Methods

In a retrospective cohort study at a university-affiliated medical center, records of women with ruptured ectopic pregnancy and massive hemoperitoneum (> 800 mL) were reviewed.

Results

Sixty women were diagnosed with ruptured ectopic pregnancy and massive hemoperitoneum: 48 underwent emergency laparoscopy; 12 underwent emergency laparotomy. There was no difference in hemodynamic status at presentation between the groups. Median operating time was significantly shorter in the laparoscopy group (50 minutes [range, 43–63 minutes] vs 60 minutes [range, 60–72 minutes]; P = 0.01). Median intra-abdominal blood loss was significantly greater in the laparotomy group (1500 mL [range, 1400–2000 mL] vs 1000 mL [range, 800–1200 mL]; P = 0.002). There was no difference between the groups regarding treatment with blood products, perioperative complications, and hospitalization period.

Conclusion

In patients with ruptured ectopic pregnancy and massive hemoperitoneum, laparoscopy is feasible and safe, with significantly shorter operating times compared with laparotomy. While the mode of surgery should be based on the surgeon’s experience and preference, the significantly lower hemoperitoneum volume associated with laparoscopy may be a reflection of shorter operating times and quicker hemorrhage control.     

The management of gynecological hemoperitoneum found to be associated with a ruptured corpus luteum cyst

Rupture of a corpus luteum cyst (RCLC) is the major cause of gynecological hemoperitoneum. RCLC is often difficult to diagnose on imaging and a standardized management is not defined. While mild cases of hemoperitoneum associated with RCLC require only observation and support, surgical intervention is necessary for severe cases or if the adnexal cyst in question is concerning for malignancy or torsion. Our study compares the outcomes of patients undergoing conservative and surgical management of gynecological hemoperitoneum found to be associated with RCLC. We performed a retrospective chart review of non-pregnant patients with a diagnosis of hemoperitoneum, corpus luteum cyst rupture, or follicular cyst rupture of the ovary between September 2007 and January 2013. The clinical characteristics, laboratory findings, and radiological findings of the women hospitalized and conservatively monitored or who underwent laparoscopy or laparotomy were reviewed for short-term and long-term adverse outcomes. Data were analyzed using Fisher’s exact test or chi-square test for categorical data and the Mann-Whitney U test for continuous data between the comparison groups. Of 30 women appearing with gynecological hemoperitoneum associated with an adnexal cyst, 5 (17 %) underwent conservative management and 25 (83 %) underwent surgical management including laparotomy (n = 11, 37 %) and laparoscopy (n = 14, 47 %). Patients predominantly presented with pelvic or abdominal pain (93 % of patients). On imaging, RCLC (or ovarian mass) was visualized on the left side in 50 % of the cases. Women younger than 30 years old were more likely to be conservatively managed (p = 0.045) and all cases of radiological concern for malignancy were surgically managed. The correct diagnosis of RCLC was made preoperatively in only 40 % of surgically managed cases. No significant difference was seen in either short-term or long-term outcomes between the two groups. RCLC is a difficult diagnosis that can appear similar to torsion or malignancy on imaging and can prompt surgical management. Though our study size was small, there was no significant difference between conservative and surgical management options in terms of short and long-term adverse outcomes in the management of ruptured corpus luteum cyst-associated hemoperitoneum.     

Corpus luteum surgery

The corpus luteum is responsible for a substantial number of emergency operations, some of which prove to be unnecessary and others which are unnecessarily complex. The routine utilization of culdocentesis and pregnancy testing will identify the large majority of those patients who can safely be treated by expectant observation or who should first be investigated by a diagnostic operative technique, such as laparoscopy, before an exploratory laparotomy is performed. When a laparotomy is performed, the ovary should be conserved whenever possible. An analysis of two hundred consecutive emergency operations for ruptured corpus luteum or corpus luteum cyst support these observations.