Uso de mifepristona en embarazo ectópico intersticial: un reporte de caso / Use of mifepristone in an interstitial ectopic pregnancy: a case report

Introducción: El embarazo ectópico intersticial es una forma de presentación poco frecuente, con una incidencia del 2-4% de los embarazos ectópicos; sin embargo, a pesar de su baja incidencia la mortalidad es cinco veces mayor, impactando en las cifras de mortalidad materna y representando en torno al 10-15% de los casos. Objetivo: Presentar un caso de embarazo ectópico intersticial, cuya ocurrencia es poco frecuente, así como el abordaje satisfactorio del manejo médico con mifepristona y metotrexato. Caso clínico: Mujer de 28 años con antecedente de resección tubárica por quiste paraovárico derecho, quien acudió a urgencias por hallazgo en ecografía obstétrica de sospecha de embarazo intersticial izquierdo y se le administró manejo farmacológico con dosis de metotrexato y mifepristona, con éxito. Conclusiones: El manejo médico con metotrexato y mifepristona para el embarazo ectópico intersticial parece ser una elección eficaz en los casos con estabilidad hemodinámica y deseo de conservación de la fertilidad.

Background: Interstitial ectopic pregnancy represents a rare form of presentation, with an incidence of 2-4% of all ectopic pregnancies. However, despite its low incidence, it is associated with a five-fold increase in mortality, significantly impacting maternal mortality rates, accounting for approximately 10-15% of cases. Objective: To present a case of interstitial ectopic pregnancy, which is a rare occurrence, as well as the successful medical management approach with mifepristone and methotrexate. Case report: A 28-year-old women with a history of right paraovarian cyst tubal resection presented to the emergency department due to suspected left interstitial pregnancy identified on obstetric ultrasound. The patient was successfully managed with pharmacological treatment using doses of methotrexate and mifepristone. Conclusions: Medical management with methotrexate and mifepristone for interstitial ectopic pregnancy appears to be an effective choice in cases with hemodynamic stability and a desire for fertility preservation.

Tratamiento quirúrgico conservador del embarazo intersticial, con antecedente de salpingectomía homolateral. Reporte de un caso / Conservative surgical management of interstitial pregnancy, with a history of ipsilateral salpingectomy. Report of a case

Resumen ANTECEDENTES: El procedimiento quirúrgico del embarazo intersticial puede complicarse con hemorragia difícil de controlar; por esto en los últimos años se recurre a las técnicas que permiten el control hemostático, con lo que disminuyen la morbilidad y mortalidad relacionadas con el procedimiento. OBJETIVO: Describir el proceso para establecer el diagnóstico y decidir el tratamiento quirúrgico conservador en una paciente con embarazo intersticial con antecedente de salpingectomía homolateral y deseo de preservación uterina. CASO CLINICO: Paciente de 27 años, con antecedentes de un parto, tres abortos y un embarazo ectópico previo, con salpingectomía izquierda. Acudió a consulta debido a un retraso menstrual de siete semanas y dolor pélvico agudo. Ante la sospecha de embarazo ectópico se integró el protocolo diagnóstico. La cuantificación de la fracción-β de hormona gonadotropina coriónica fue de 8962 mlU/mL, el ultrasonido transvaginal reportó una imagen compatible con saco gestacional hacia la región del cuerno izquierdo y probable hemoperitoneo. En la laparotomía exploradora se encontraron: hemoperitoneo y embarazo intersticial izquierdo. Con el propósito de preservar la fertilidad se hizo una doble ligadura de la arteria uterina izquierda, a nivel de istmo uterino y del ligamento útero-ovárico y resección del saco gestacional intersticial, con cornuostomía. CONCLUSION: El embarazo intersticial es una urgencia obstétrica con alto riesgo de ruptura y hemorragia, por fortuna poco frecuente. La ligadura de las arterias uterinas, previa a la ablación quirúrgica del saco gestacional, es una alternativa individualizada en pacientes con esta complicación.

Abstract BACKGROUND: The surgical procedure of interstitial pregnancy can be complicated by bleeding that is difficult to control; for this reason, in recent years, techniques that allow hemostatic control to have been used, thus reducing morbidity and mortality related to the procedure. OBJECTIVE: To describe the process to establish the diagnosis and decide the conservative surgical treatment in a patient with interstitial pregnancy with a history of homolateral salpingectomy and desire for uterine preservation. CLINICAL CASE: 27-year-old patient, with a history of one childbirth, three miscarriages and a previous ectopic pregnancy, with left salpingectomy. She came for consultation due to a seven-week menstrual delay and acute pelvic pain. In view of the suspicion of ectopic pregnancy, the diagnostic protocol was integrated. The quantification of the β-fraction of chorionic gonadotropin hormone was 8962 mlU/mL, the transvaginal ultrasound reported an image compatible with gestational sac towards the left horn region and probable hemoperitoneum. At exploratory laparotomy, hemoperitoneum and left interstitial pregnancy were found. To preserve fertility, a double ligation of the left uterine artery at the level of the uterine isthmus and the utero-ovarian ligament and resection of the interstitial gestational sac with cornuostomy was performed. CONCLUSION: Interstitial pregnancy is an obstetric emergency with a high risk of rupture and hemorrhage, fortunately rare. Ligation of the uterine arteries, prior to surgical ablation of the gestational sac, is an individualized alternative in patients with this complication.

Experiencias en el tratamiento del embarazo ectópico del cuerno uterino / Treatment experiences about uterine horn ectopic pregnancy

Introducción: El embarazo intersticial es poco frecuente y su mortalidad es superior a otras localizaciones. Su diagnóstico cada vez más precoz, permite escoger tratamientos menos agresivos. La piedra angular, es la hemostasia. Objetivo: Describir los resultados del tratamiento de pacientes atendidas por embarazo ectópico del cuerno. Método: Se realizó un estudio descriptivo en 18 mujeres con embarazo ectópico intersticial, atendidas en el Hospital Militar Central Dr. Luis Díaz Soto del 2010 al 2019. Fueron tratadas mediante laparotomía y sutura circular del cuerno, con posterior resección cornual y extracción del material ovular. Se estudiaron las variables edad, factores de riesgo, tiempo quirúrgico, sangramiento transoperatorio, evolución (complicaciones, recuperación, fracción beta de la gonadotropina coriónica, controles ecográficos posoperatorios) y estadía hospitalaria. Resultados: El 72 por ciento de las pacientes estuvo entre 20 - 25 años, el 61,1 por ciento tuvo antecedentes de abortos provocados, seguido de enfermedad inflamatoria pélvica en el 44,4 por ciento. La media del tiempo quirúrgico fue de 36 minutos. Ninguna paciente tuvo sangramiento en el sitio de la cirugía. La fracción beta de la gonadotropina coriónica, se negativizó a la cuarta semana y los controles ecográficos posoperatorios de todas las pacientes fueron normales el día 15. En todas las pacientes se utilizó la sutura en jareta. Conclusiones: Los resultados en el tratamiento de las pacientes atendidas por embarazo instersticial, fueron favorables, la reparación de la pared uterina se realizó mediante un procedimiento seguro que mostró la aplicabilidad de la sutura en jareta. Se evitaron las pérdidas sanguíneas y complicaciones como la histerectomía(AU)

Introduction: Interstitial pregnancy is rare and its mortality is higher than in other locations. Its increasingly early diagnosis allows the choice of less aggressive treatments. The cornerstone is hemostasis. Objective: To describe the results of the treatment of patients treated for ectopic horn pregnancy. Method: A descriptive study was carried out in 18 women with interstitial ectopic pregnancy, treated at the Hospital Militar Central Dr. Luis Díaz Soto from 2010 to 2019. They were treated by laparotomy and circular suture of the horn, with subsequent cornual resection and extraction of ovular material. The variables age, risk factors, surgical time, intraoperative bleeding, evolution (complications, recovery, beta fraction of chorionic gonadotropin, postoperative ultrasound controls) and hospital stay were studied. Results: 72 percent of the patients were between 20 - 25 years old, 61.1 percent had a history of induced abortions, followed by pelvic inflammatory disease in 44.4 percent. The mean surgical time was 36 minutes. No patient had bleeding at the surgery site. The beta fraction of chorionic gonadotropin was negative at the fourth week and postoperative ultrasound controls of all patients were normal on day 15. The drawstring suture was used in all patients. Conclusions: The results in the treatment of the patients attended for interstitial pregnancy were favorable, the repair of the uterine wall was carried out by means of a safe procedure that showed the applicability of the drawstring suture. Blood loss and complications such as hysterectomy were avoided(AU))

Diagnostic dilemmas of an eccentrically located gestation sac: role of 3D ultrasound

Background: Differential diagnosis of an eccentrically located sac includes interstitial pregnancy, true cornual pregnancy and angular pregnancy which may all look similar on 2D (two dimensional) ultrasound. Interstitial pregnancy is associated with a higher maternal mortality and needs to be differentiated from true cornual pregnancy and angular pregnancy. This paper is an illustration of the role of 3D (three dimensional) ultrasound in differential diagnosis and management of the three entities.Methods: 2D and 3D ultrasound findings were analyzed in 10 cases of eccentrically located sac. The role of 3D ultrasound in differentiating the three entities had been evaluated.Results: The presence of an eccentrically located gestation sac with incomplete or asymmetric myometrial tissue less than 5 mm in thickness on 2D and the coronal sections obtained from 3D scans were used for diagnosis of interstitial pregnancy in three cases. 2 cases of angular pregnancy were diagnosed based on the finding of sac located in one of the lateral angles of the uterus with broad based connection to the endometrium. 2 cases of cornual pregnancy one intrauterine in a bicornuate uterus and the other in a rudimentary horn has been described. One heterotopic pregnancy and two other cases where a cornual fibroid mimics interstitial pregnancy is also illustrated.Conclusions: The role of 3D ultrasound in differentiating the three entities and the key findings in obtaining the precise diagnosis are emphasized. Routine usage of 3D ultrasound in all cases of eccentrically located gestational sac is recommended.

Misdiagnosis of interstitial pregnancy followed by circlage operation and failed induced midtrimester abortion: a case report

Interstitial pregnancy is rare form of ectopic pregnancy that can expand up to 18 weeks leads to massive haemoperitoneum hence early diagnosis is imperative to decrease mortality and morbidity. Present case diagnosed as interstitial pregnancy at laparotomy when she had taken for hysterotomy after two failed courses of medical abortion. Clinicians should bear in mind the limitations of various investigations and should have a higher degree of suspicion for interstitial pregnancy Any deviation from normal response to administration of medical abortificient, such as failure to abort, should instigate the diagnosis of ectopic (interstitial) pregnancy by expert radiologist.

Embarazo ectópico intersticial tratado con metotrexato y cirugía: caso clínico / Interstitial ectopic pregnancy treated with methotrexate and surgery: clinical case

RESUMEN Antecedentes: El embarazo intersticial es muy inusual y representa <2,4% de todos las gestaciones ectópicas. Objetivo: Se presenta el caso de un embarazo ectópico intersticial tratado de forma médica y quirúrgica. Se realiza una revisión literaria sobre las opciones de manejo y tratamiento. Caso clínico: Paciente primigesta de 36 años con gestación ectópica cornual derecha tras 11 días de la transferencia de un embrión criopreservado. Se decide tratamiento con metotrexato (MTX) sin éxito y con progresión del embarazo, obligándonos por lo tanto a realizar una evacuación quirúrgica de la gestación, exponiendo a la paciente tanto a los efectos secundarios del tratamiento médico como a los del abordaje quirúrgico. Conclusión: El embarazo ectópico intersticial sigue siendo un reto para el ginecólogo. El diagnóstico muy temprano de estas patologías, aunque difícil, podría evitar la opción quirúrgica, siendo el MTX más eficaz en los casos tratados precozmente.

ABSTRACT Background: Interstitial pregnancy is very unusual, and it represents <2,4% of all ectopic pregnancies. Objective: We present the case of an interstitial ectopic pregnancy treated medically and surgically. A literary review is also made about the management and treatment options. Clinical case: A 36-year-old patient with a diagnosis of right cornual ectopic pregnancy after 11 days of a cryopreserved embryo's transfer. Methotrexate (MTX) treatment was applied as the initial step but without lasting results. Because of the progression of the pregnancy, further therapy was focused on its surgical evacuation exposing the patient to the side effects of both medical treatment and surgical approach. Conclusion: Interstitial ectopic pregnancy remains a challenge for the gynecologist. Very early diagnosis of these pathologies, although difficult, could avoid the surgical outcome, being MTX more effective in cases intervened initially.

Clinical observation on the effect of Guizhi Fuling pill on the treatment of interstitial tubal pregnancy / 中国生化药物杂志

Objective To observe the clinical effect of Guizhi Fuling pill in the treatment of interstitial tubal pregnancy.Methods80 cases with interstitial tubal pregnancy in Hangzhou obstetrics and gynecology hospital from August 2015 to December.2016 were randomly divided into the observation group and the control group, 40 cases in each group.The control group were given methotrexate and mifepristone, at this basis, the observation group were given Guizhi Fuling pill.The effect was analyzed in the two groups.Results①β-HCG negative time in the observation group were significantly shorter than that in the control group(P<0.05).②Adverse reactions rate in the observation group was significantly lower than that in the control group(P<0.05).ConclusionIt can shorten the treatment time, reduce the adverse reaction which Guizhi Fuling pill was used in the adjuvant treatment of interstitial tubal pregnancy.

Treatment of interstitial tubal pregnancy with Guizhi Fuling pill assisted with methotrexate and mifepristone / 中国生化药物杂志

Objective To analyze treatment of tubal interstitial pregnancy with Guizhi Fuling pill assisted with methotrexate and mifepristone.Methods 90 cases tubal interstitial pregnancy patients from January 2015 to June 2016 were grouped by admission order and each group with 45 cases.Methotrexate and mifepristone therapy were given the control group,Guizhi Fuling pill assisted with methotrexate and mifepristone were given the observation group.Treatment success rate,β-HCG negative time,mass disappearance time,length of hospitalization and adverse reactions were compared.Results (After treatment,treatment success rate of observation group was 91.11％and 80.49％of tubal smooth,witch all higher than control group with(88.89％,77.50％),but the difference was not statistically significant.(For the treatment of two groups of patients with success,β-HCG negative time,mass disappearance time and length of hospitalization of observation group were(13.05±1.08,24.09±1.43,15.37±0.82)days,shorter than control group with(17.39±1.50,27.43±2.19,18.85±1.)days(P<0.05).③ During treatment,adverse reactions of observation group was 11.11％,lower than control group with 26.67％(P<0.05).Conclusion Guizhi Fuling pill assisted with methotrexate and mifepristone can shorten treatment time and reduce side effects for tubal interstitial pregnancy patients.

Embarazo ectópico cornual recurrente: caso clínico y revisión de la literatura / Recurrent cornual ectopic pregnancy: clinical case and literature review

OBJETIVO: Reportar un caso de embarazo ectópico cornual recurrente, al que se le realizó manejo por laparoscopia. Realizar una revisión de la literatura sobre este tema. CASO CLÍNICO: Se presenta el caso de una paciente de 34 años, con embarazo cornual recurrente a quien se le realizó manejo exitoso por laparoscopia. MÉTODO: Se realizó una búsqueda bibliográfica en las bases de datos con las palabras clave: pregnancy, intersticial y cornual ectopic en Medline, PubMed, Embase, Cochrane Data base, Ovid, Hinari, Scielo y Bireme. Resultados: La búsqueda inicial arrojó 311 artículos, de los cuales se seleccionaron 116 y posteriormente 74 artículos, que estaban relacionados con el tema a revisar, finalmente se escogieron 38 artículos con texto completo. CONCLUSIÓN: El embarazo ectópico cornual o intersticial tienen los mismos factores de riesgo que el embarazo tubárico. El avance en ecografía y los niveles de ßHCG han permitido un diagnóstico precoz, lo que permite realizar tratamientos médico o quirúrgico más conservadores, donde la laparoscopia ha empezado a tener un papel muy importante.

OBJECTIVE: To report a recurrent cornual ectopic pregnancy who underwent laparoscopic management and review the literature on this topic. CASE REPORT: 34 year-old patient with a recurrent cornual ectopic pregnancy who underwent successful laparoscopic management. METHOD: A literature search was performed in databases Medline, PubMed, Embase, Cochrane Data Base, Ovid, Hinari, Scielo and Bireme, with the keywords: pregnancy, interstitial and cornual ectopic pregnancy. Results: The initial search yielded 311 articles of which 116 were selected and then 74 who were related to the subject to review, finally 38 full text articles were selected. CONCLUSION: Cornual or interstitial ectopic pregnancy has the same risk factors that tubal pregnancy. Advances in ultrasound and ßHCG levels have allowed earlier diagnosis allowing more conservative treatments either medical or surgical treatment where laparoscopy has begun to play an important role.

Conservative Surgery Under Laparascope in the Treatment of Interstitial Tubal Pregnancy:a Report of 24 Cases / 中国微创外科杂志

Objective To explore the safety and feasibility of conservative laparoscopic salpingotomy and embryo removal . Methods A total of 24 patients with tubal interstitial pregnancy underwent laparoscopic salpingotomy and embryo removal between January 2012 and January 2014.A longitudinal incision was made on the bulge lesions under laparoscope .The gestational sac and affiliated organizations were removed and the incision was continuously sutured with absorption threads .Results The operation was completed in all the 24 patients.The operation time was ( 33.5 ±6.2 ) min, and the blood loss was ( 40.6 ±9.4 ) ml.No postoperative persistent salpingocyesis occurred .The postoperative serum β-hCG recovery time was (14.2 ±4.6) d.Postoperative hysterosalpingography showed unobstructed fallopian tube in 13 patients, connected but not patent in 4 patients, and blocked in 5 patients. Conclusion Laparoscopic salpingotomy and embryo removal is safe and effective , with the patency of fallopian tube partly retained.

Pregnancy Following Laparotomy for Ruptured Interstitial Pregnancy.

An interstitial pregnancy is an uncommon type of ectopic pregnancy, accounting for 2-4% of all ectopic pregnancies. We present a patient with history of ruptured interstitial pregnancy who had been managed successfully at our hospital. The patient had refused tubectomy and conceived against medical advice within six months after laparotomy. She was counseled for risk of rupture of uterus and admitted to the hospital at the beginning of 9th month. She underwent an elective cesarean section and a male baby was delivered. Palpation of the uterine scar revealed that it was papery thin. Had there been any delay, the uterus would have ruptured with resultant maternal and fetal morbidity and mortality.

Embarazo cornual: tratamiento médico con dosis única de metotrexato / Cornual pregnancy treated with single intramuscular methotrexate dose

Presentamos un caso de embarazo cornual o intersticial diagnosticado en forma precoz a través de ecografía transvaginal, tratado exitosamente, en forma conservadora, con dosis única sistémica de metotrexato.

We present a case of cornual or interstitial pregnancy diagnosed during early stage through transvaginal ultrasound, treated successfully with single systemic intramuscular methotrexate dose.

Incidental Detection of Interstitial Pregnancy on CT Imaging

Ectopic pregnancy is a potentially life-threatening condition. Detection of ectopic pregnancy on CT images is rare. In this case, we describe the CT findings of interstitial pregnancy both before and after rupture. If CT images demonstrate the presence of a strong enhancing ring-like mass in the pelvis, ectopic pregnancy should be considered.

Diagnosis of an Interstitial Pregnancy with 3-dimensional Transvaginal Sonography / 대한주산의학회잡지

Interstitial pregnancy is an ectopic pregnancy which is located in the intramural portion of the tube covered by myometrium. Rupture usually results in catastrophic hemorrhage, since there is an anastomosis of uterine artery and tuboovarian vessels. Therefore, the early diagnosis is important to decrease maternal morbidity. However, the diagnosis using the conventional 2-dimensional transvaginal sonography has some difficulties in differentiation from corneal pregnancy. In this case, we diagnosed an interstitial pregnancy using the 3-dimensional sonography in a woman with amenorrhea for 7 weeks and 1 days, which was resected through laparoscopic operation. The 3-dimensional sonography has a potential role to define the location of pregnancy implanted on the outer site of uterine fundus.

Diagnosis of an Interstitial Pregnancy with 3-dimensional Transvaginal Sonography / 대한주산의학회잡지

Interstitial pregnancy is an ectopic pregnancy which is located in the intramural portion of the tube covered by myometrium. Rupture usually results in catastrophic hemorrhage, since there is an anastomosis of uterine artery and tuboovarian vessels. Therefore, the early diagnosis is important to decrease maternal morbidity. However, the diagnosis using the conventional 2-dimensional transvaginal sonography has some difficulties in differentiation from corneal pregnancy. In this case, we diagnosed an interstitial pregnancy using the 3-dimensional sonography in a woman with amenorrhea for 7 weeks and 1 days, which was resected through laparoscopic operation. The 3-dimensional sonography has a potential role to define the location of pregnancy implanted on the outer site of uterine fundus.

Interstitial pregnancies treated by endoscopic cornuotomy after ingection of large amount of diluted vasopressin / 대한산부인과학회지

OBJECTIVE: Our aim was to report an effective procedure of injection of large amount of diluted vasopressin in the treatment of interstitial pregnancy using endoscopic cornuotomy METHODS: This is an uncontrolled retrospective study of 17 patients interstitial pregnancies treated of by endoscopic cornuotomy from June 2001 to June 2004 in our hospital. All cases were applied by the large amount of diluted vasopressin injection. RESULTS: Among 446 ectopic pregnancies, interstitial pregnancies were 17 (3.81%). Fourteen patients (82.4%) were unruptured, three patients (17.6%) were ruptured. Mean (+/-SD) age and parity of patients were 35.6+/-3.9 years (range 30-40 years), 1.5+/-2.1 (range 0-3), respectively. At the time of operation the duration of amenorrhea and mean size of ectopic gestation were 54.5+/-9.6 day and 2.6 x 2.6 cm, respectively. The amount of injected vasopressin was 190.0+/-55.5 cc. For the cornual closure, the endosuture method was applied in 10 patients (59%), and the endoloop method was applied in 7 patients (41%) The mean (+/-SD) blood loss and operation time were 18.2+/-15.9 cc and 28.3+/-7.8 minute, respectively. In fifteen patients (88%), serum beta-hCG level from the preoperative base was declined 90% or more within postoperative day 4 and in 2 patients (12%), it was decreased within postoperative day 60. CONCLUSION: Endoscopic cornuotomy using the large amount of diluted vasopressin injection procedure is a safe and effective in the interstitial pregnancy.

Laparoscopy Combined with Uterine Aspiration for Tubal Interstitial Pregnancy and Cornual Pregnancy / 中国微创外科杂志

Objective To discuss the efficacy of laparoscopy combined with uterine aspiration for tubal interstitial pregnancy and cornual pregnancy. Methods From January 2004 to January 2007,laparoscopy combined with the preservation of the oviducts was performed on 56 patients with tubal interstitial pregnancy or cornual pregnancy. During the operation,the ectopic pregnancy tissues were removed,and then uterine aspiration was carried out. Results The operation was completed in all of the cases without conversion to open surgery. One of the patients showed persistent ectopic pregnancy,and was cured by muscular injection of MTX injection. In this series,the rate of oviduct patency was 33.9% (19/ 56); 18 moths after the operation,the uterine pregnancy rate was 71.4% (40/56),ectopic pregnancy rate was 16.1%(9/56),and the secondary infertility rate was 1.2% (7/56). Conclusions It is safe and effective to treat tubal interstitial pregnancy or cornual pregnancy with laparoscopic operation combined with uterine aspiration.

Suction and Evacuation of Ectopic Conceptus by Laparoscopic Cornuostomy in Interstitial Pregnancy: 2 cases / 대한산부인과학회잡지

Interstitial pregnancy is a rare but very dangerous event if it would be ruptured and it occurs in about 1% of ectopic pregnancy. With recent advances in laparoscopic surgery many reports have been described laparoscopic cornual resection for interstitial pregnancy or laparoscopic cornuostomy as a safe alternative to laparotomy. We report two cases of unruptured interstitial pregnancy treated by laparoscopic cornuostomy with suction and evacuation of conceptus. This might be a safer and less destructive method by minimal incision of cornual lesion and suction/evacuation of the ectopic conceptus without myometrial reconstruction.

Endoscopic Management of Cornual Pregnancy

Cornual interstillal pregnancy is a rate form of ectopic pregnancy. It usually has catastrophic prcsentations but in this case patient presented as missed abortion and was diagnosed as degenerating cornual my oma on ultrasound. This case was managed endoscopically by cornual evacuation of small friable ball of tissue which on histopathology was confirmed to be products of conception. Endoscopic management has man) advantages over conventional methods.

Live cornual pregnancy

We report a case of a singleton cornual (interstitial) pregnancy following spontaneous conception in a primigravida with no risk factors for ectopic pregnancy. She presented at 34 weeks gestation with hemoperitoneum, due to a rupture on the anterior surface of the cornual pregnancy. At laparotomy, the point of rupture was extended vertically, delivering a live baby boy.