特殊部位异位妊娠的分析及进展

异位妊娠是妇科常见急腹症之一,随着妇科炎症、性传播疾病、宫腔操作和剖宫产率的不断攀升,特殊部位异位妊娠的发病率也在逐年增加.特殊部位异位妊娠包括子宫瘢痕、卵巢、残角子宫、子宫颈及腹腔等少见部位的异位妊娠.临床表现缺乏特异性、体征不典型,故早期诊断困难,极易误诊,严重威胁患者的生命.随着专科医生对异位妊娠的警惕性不断提高,超声对异位妊娠诊断依据的不断规范及患者对优生优育知识认知的不断深入,特殊部位异位妊娠给患者造成的威胁也在逐年减少.特殊部位异位妊娠除有停经、腹痛、阴道出血三大临床表现外,还各有特点.重视其临床表现及各自特点,早期诊断、及时治疗是妇产科临床医生及全科医院急症科医生面对的重要课题.     

宫内早孕合并左侧输卵管伞部妊娠一例及文献复习

宫内孕合并异位妊娠临床罕见,近年来随着辅助生殖技术的兴起,其发病率有所上升。其临床表现不一,主要取决于种植于宫腔外的异位妊娠胚胎的发育情况,轻者可无明显症状或体征,严重者可致患者腹腔大出血、失血性休克甚至死亡。由于宫内孕合并异位妊娠十分凶险,临床上应尽早诊断,采取个体化治疗,以确保母儿安全。现报道1例罕见的宫内早孕合并左侧输卵管伞部妊娠病例,并进行相关文献复习,总结宫内孕合并异位妊娠的相关知识,以期引起妇产科医生的重视。     

分娩期非瘢痕子宫自发性破裂一例

子宫破裂是指在分娩期或妊娠晚期子宫体部、底部或子宫下段发生裂开,直接威胁产妇及胎儿生命,是产科急危重症。最常见的原因是子宫操作史和梗阻性难产,其次还有子宫发育畸形、子宫肌层发育不良、剖宫产切口选择不当以及阴道助产损伤等。主要临床表现是胎心异常、腹痛和阴道出血。对于无子宫破裂高危因素且临床症状不典型的患者发生子宫破裂容易出现漏诊。讨论分析石家庄市第四医院收治的1例分娩期非瘢痕子宫自发性破裂病例,为该病的早期识别、早期诊断和及时处理提供帮助。     

各孕周宫角妊娠38例临床分析

目的 探讨各孕周宫角妊娠的临床特点、诊断和治疗方法.方法 对2006年1月至2010年8月郑州大学第一附属医院收治的38例宫角妊娠的患者进行回顾性的分析.结果 38例宫角妊娠的患者中,停经38例(100%)、不规则阴道出血27例(71.1%)和腹痛22例(57.9%).宫角妊娠术前诊断困难,误诊率近50%.38例患者中...     

Spontaneous uterine artery rupture during pregnancy in a woman with sickle cell disease: a case report

BACKGROUND: Spontaneous rupture of uterine vessels during pregnancy is rare and usually involves uteroovarian veins. Presenting symptoms include acute-onset abdominal pain and maternal hypovolemic collapse due to hemoperitoneum. An atypical case of subacute uterine artery rupture at 27 weeks of gestation occurred in a woman with sickle cell disease. CASE: A 28-year-old, nulliparous woman with sickle cell disease was admitted at 27 weeks of gestation for sharp abdominal pain radiating to the right flank. The first diagnosis included acute renal colic and a sickling vasoocclusive crisis. One week after admission the patient experienced paroxysmal, diffuse abdominal pain associated with acute fetal distress requiring an emergency cesarean section. Laparotomy revealed an 800-mL hemoperitoneum. Active bleeding from a ruptured uterine artery was observed and successfully treated by selective suture. CONCLUSION: Spontaneous rupture of the uterine artery during pregnancy may present as a 2-step process.     

Spontaneous Uterine Rupture in a Primigravida at 35 Weeks of Gestation. A Case Report and Review of the Literature

Spontaneous uterine rupture is a rare but life-threatening event. Usually, this complication is associated with such risk factors as previous injury of the uterine wall. We report a case of spontaneous rupture of an unscarred uterus in the absence of classical risk factors, and review the literature with respect to the possible aetiologies of this condition. We conclude that the differential diagnosis of atypical abdominal pain in pregnancy should include spontaneous uterine rupture, even in the absence of classical risk factors.     

原发性腹腔妊娠的临床诊断和治疗分析——附1例病例报道

目的:探讨腹腔妊娠的诊断以及治疗方案,以提高对该病的认识、降低患者死亡率以及减少产后并发症。方法:回顾性分析和总结我院收治的1例原发性腹腔妊娠的诊断及治疗方案。结果:该病例氨甲喋呤(MTX)保守治疗效果不理想,后经腹腔镜检查明确诊断,同时成功予以手术治疗。结论:腹腔妊娠临床症状不典型,早期诊断较困难,腹腔镜技术是一种有效的诊断和治疗方法,腹腔妊娠的早期诊断可明显改善预后。     

Successful laparoscopic management of early splenic pregnancy: case report and review of literature

Splenic pregnancy is the least common form of ectopic pregnancy. A 32-year-old woman, gravida 5, para 2, had not menstruated for 46 days, and had spotty bleeding for 6 days and lower abdominal pain for 2 days. The initial β-human chorionic gonadotropin concentration was 38,913.3 IU/L. Transvaginal ultrasound examination demonstrated an empty uterine cavity, and a gestational sac 4.3 × 4.0 mm in diameter, with no fetal pole or yolk sac, located just adjacent to the splenic region. Laparoscopic surgery demonstrated intact pelvic organs and an ectopic mass on the spleen. The splenic pregnancy was successfully treated via laparoscopic embryo methotrexate injection, with preservation of the uterus and spleen. As evidenced in this case, laparoscopic embryo methotrexate injection is a minimally invasive and effective method of diagnosis and treatment of early splenic pregnancy.     

Uterine rupture of placenta accreta

The uterine rupture during pregnancy is one of the most serious complications, increase morbidity and maternal and fetal mortality. The uterine rupture by percrete placenta is rare. We present the case of a 39 years-old patient, pregnancy of 16.3 weeks by ultrasound, which enters by abdominal pain 48 hours of evolution, of predominance in the hypogastric region, that during its evolution presented hemodynamic compromise and increase of abdominal pain. By ultrasound: free liquid in abdominal cavity is observed. With laparothomy we found perforated uterus with placenta free and product in abdominal cavity, obstetrical hysterectomy was performed, we confirmed the diagnosis of uterine rupture by percrete placenta.     

Rupture of a pregnant unscarred uterus in an early secondary trimester: a case report and brief review

Rupture of a pregnant uterus in early pregnancy and an unscarred uterus are extremely rare, and some non-specific symptoms might appear before this occurrence. We report the case of a multiparous woman (gravida 3, para 2) with uterine fundal rupture in her early second trimester (17+ weeks of gestational age), who presented upper abdominal discomfort and vomiting for 3 days, and progressed into sudden acute abdomen and shock. During emergent laparotomy, the entire amniotic sac was found in the peritoneal cavity with a rupture of the uterine fundus. Although we could not confirm that the appearance of upper gastrointestinal symptoms and severe vomiting was associated with uterine rupture in this pregnant woman, abdominal symptoms or signs might be a hint or cause of severe catastrophic pregnancy-related complications.     

Term extrauterine pregnancy in a Nigerian mother: a complication of uterine dehiscence

Abdominal pregnancy is an uncommon but life-threatening form of ectopic pregnancy. It is associated with high maternal/fetal morbidity and mortality. We present a rare case of term abdominal pregnancy resulting from anterior uterine wall dehiscence, in a 36-year-old woman with three previous caesarean sections. The diagnosis was made at laparotomy for the fourth “caesarean section”.     

Spontaneous twin cervico-isthmic pregnancy in a grand multiparous woman

Cervico-isthmic pregnancy is a rare form of ectopic pregnancy and is defined as the implantation of a fertilized ovum in the cervico-isthmic portion. The cause is unknown; local pathology related to previous cervical or uterine surgery may play a role, given an apparent association with a prior history of curettage or cesarean delivery. Transvaginal ultrasonography and β-human chorionic gonadotrophin assays are useful for diagnosis. Here we report a case of spontaneous twin cervico-isthmic pregnancy in a grand multiparous patient who was diagnosed early in the first trimester with transvaginal ultrasonography. The pregnancy was terminated successfully with methotrexate. Methotrexate seems to be most successful at early gestational ages.     

Torsion of a nongravid uterus with a large ovarian cyst: usefulness of contrast MR image

Torsion of a nongravid uterus is extremely rare. Most cases of uterine torsion occur during pregnancy. Here we report a case of nongravid uterus torsion with a large adnexal mass. A 73-year-old woman presented at the emergency room with acute abdominal pain. A preoperative diagnosis of torsion of an ovarian cyst was made and laparotomy was performed. The left ovary was twisted 360 degrees in a clockwise rotation, and the uterine corpus had also undergone a 360 degrees rotation. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were carried out. Although a preoperative diagnosis of uterine torsion was not possible, it is noteworthy that in the contrast-enhanced magnetic resonance images the uterine cervix was intensely enhanced, while the uterine corpus was not. This is the first report to show the magnetic resonance imaging findings of a twisted uterus.     

The impact of leiomyomas on pregnancy

In this retrospective case control investigation, 51 pregnant patients who were diagnosed by ultrasound with uterine myomas were compared to 102 randomly selected control patients to determine if the ultrasound diagnosis of one or more leiomyoma is associated with increased untoward pregnancy outcomes compared to controls. Women with uterine myomas were older (p = 0.001), more likely to be African American (p = 0.001), and undergo Caesarean delivery (p = 0.03) than controls. However, when women who underwent abdominal delivery for previous myomectomy (n = 5) were excluded from analysis, there was no significant difference in the incidence of Caesarean delivery. Overall, there was no difference in the incidence of obstetric complications between groups even when the data was stratified for large and/or multiple leiomyomas. The discovery of uterine leiomyomas by gestational ultrasound does not appear to place the patient at increased risk for preterm labour, early delivery, or other untoward pregnancy outcomes.     

Expectant management of a herniated amniotic sac presenting as silent uterine rupture: a case report and literature review

Foetal membranes bulging into the abdominal cavity is a unique initial manifestation of silent or complete uterine rupture during pregnancy. Since silent uterine rupture has potential risk for complete uterine rupture, which leads to acute life-threatening complications for both the mother and baby, it is difficult to determine whether to manage expectantly or surgically, including repair of the uterine wall or termination of the pregnancy, especially in the early second trimester. We present here a case of a herniated amniotic sac with overstretched uterine wall of the fundus presenting as silent uterine rupture, which was incidentally detected on routine ultrasonography at 18 weeks' gestation in a 38-year-old primigravida with a history of myomectomy for diffuse uterine leiomyomatosis. Magnetic resonance imaging examination revealed that the myometrium thickness was fully maintained at the site of the foetal membranes ballooning. The pregnancy was therefore managed expectantly and continued to successful delivery at 30 weeks' gestation. The precise assessment of the uterine wall may be essential to manage a herniated amniotic sac presenting as silent uterine rupture and to optimise the outcome of the pregnancy. We review all cases of a herniated amniotic sac out of focally overstretched uterine wall before 34 weeks' gestation.     

Comparison of magnetic resonance imaging and ultrasonography in the early diagnosis of interstitial pregnancy

OBJECTIVE: To investigate the usefulness of ultrasonography (USG) and magnetic resonance imaging (MRI) in the early diagnosis of interstitial pregnancy. STUDY DESIGN: Four cases of interstitial pregnancy that showed characteristic ultrasonographic and MRI findings were studied. All cases received cornual resection, and the presence of interstitial pregnancy was confirmed by pathologic examination. RESULTS: Three of four cases had a gestational sac in the uterine cornu or a protruding cornual mass and myometrium between the sac and uterine cavity on both USG and MRI. In the remaining case, preoperative diagnosis was inconclusive because no gestational sac was demonstrated by USG or MRI. Color flow mapping was conducted in three cases and revealed prominent peritrophoblastic blood flow. CONCLUSION: The findings suggest that USG combined with color flow mapping is the first choice in the early diagnosis of interstitial pregnancy. MRI, which is an extremely expensive imaging technology, should be used only if transvaginal USG with color flow mapping is inconclusive in ruling out the diagnosis of interstitial pregnancy.     

Combination of transarterial embolization of uterine arteries and conservative surgical treatment for pregnancy in a cesarean section scar. A report of 3 cases

BACKGROUND: Pregnancy developing within a previous cesarean section scar is one of the rarest kinds of ectopic pregnancy. It can result in term pregnancy and therefore must be distinguished from cervical pregnancy. Irregular vaginal bleeding is common, but massive bleeding may lead to life-threatening situations. The treatment for postabortal or postpartal hemorrhage is total or subtotal hysterectomy. CASES: Three cases of pregnancy within scars from previous cesarean sections are reported. Two patients were transferred to our hospital due to postabortal hemorrhage for unwanted pregnancy. The third patient went to the emergency department for low abdominal pain with vaginal spotting and was mis-diagnosed as having a tubal pregnancy from the initial ultrasound examination. Exploratory laparotomy was done for evacuation of the abnormally implanted conception tissue. Transarterial embolization of bilateral uterine arteries (UAs) was performed to stop postoperative bleeding in one case and to prevent intraoperative hemorrhage in the other two. Subsequently, the postoperative bleeding case underwent cesarean delivery of a full-term infant following an uneventful pregnancy. CONCLUSION: Conservative surgical treatment following transarterial embolization of bilateral uterine arteries is an alternative method of managing the patients with early pregnancy in the scar from a cesarean section. This technique preserves the uterus and greatly reduces morbidity.     

Isolated torsion of the fallopian tube during pregnancy: a case report

BACKGROUND: Isolated fallopian tube torsion during pregnancy is a rare condition, and only 16 cases have been reported. In all but 1 case the right tube was affected. We report the second case of isolated left fallopian tube torsion during pregnancy. CASE: A 23-year-old primigravida presented at 22 weeks of gestation with left lower abdominal pain. Sonography depicted a simple cystic mass adjacent to the left uterine border. Laparotomy revealed torsion of the left hydrosalpinx together with a paraovarian cyst. The patient delivered a healthy infant at term after an otherwise-uneventful pregnancy. CONCLUSION: As the gravid uterus increases the risk for fallopian tube torsion, this condition should be included in the differential diagnosis of lower abdominal pain during pregnancy.     

Second-trimester presentation of placenta percreta

Placenta percreta is diagnosed usually in the third trimester as massive postpartum hemorrhage when an attempt to remove the placenta reveals lack of a cleavage plane. However, placenta percreta may present in the second trimester with signs and symptoms of uterine rupture. The diagnosis of this event may be difficult because of mild abdominal discomfort often associated with normal pregnancy. We describe two cases that occurred in the second trimester with an unusual presentation. Both patients suffered considerable surgical morbidity. Other cases reported in the literature are mentioned as well. When a patient with risk factors for abnormal placentation presents with abdominal pain and/or vaginal bleeding in the second trimester of pregnancy, the diagnosis of placenta percreta should be considered. A laparotomy is indicated immediately when hemoperitoneum is suspected because uterine rupture has most likely occurred. Placenta percreta in the second trimester is a potentially life-threatening condition that warrants expeditious diagnosis to limit maternal postoperative morbidity.     

Abdominal pain in pregnancy: a rational approach to management

Abdominal pain is a relatively common symptom during pregnancy and may be due to anatomical and physiological changes of the pregnant state, such as the ‘round ligament strain’ or may be due to an underlying pathological process. Various obstetric conditions such as placental abruption, clinical chorioamnionitis, threatened pre-term labour and uterine rupture may present with acute abdominal pain. Pregnancy also may predispose to certain clinical conditions such as urinary tract infection that may present with abdominal pain. Conversely, inflammatory or neoplastic processes that are totally unrelated to the pregnant state may first make their presentation during pregnancy, with acute or chronic abdominal pain. Acute abdomen refers to an intra-abdominal process that is characterised by abdominal pain, tenderness and muscular rigidity, for which an emergency surgery must be considered. Life-threatening conditions such as acute appendicitis, acute pancreatitis and intra-peritoneal infection or haemorrhage may result in such an ‘emergency’. It is important to appreciate that pregnancy may alter the clinical presentation of these life-threatening conditions and hence, may ‘mask’ their classical symptoms and signs, delaying the definitive diagnosis. In addition, the presence of a fetus may affect diagnosis and management. Timely diagnosis and appropriate treatment of conditions contributing to abdominal pain and acute abdomen during pregnancy, is essential to improve maternal and perinatal outcome.