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La gestación extrauterina se denomina embarazo ectópico, esta es una emergencia obstétrica del primer trimestre, que cada vez está teniendo una incidencia mayor. Una de las localizaciones en las que se pueden generar estas gestaciones es la cicatriz de cesárea previa, lo cual supone un reto para el ginecólogo tratante debido a su dificultad diagnóstica y opciones terapéuticas. Se reporta el caso de una paciente de 37 años que ingresó por el servicio de emergencia con 6 semanas de amenorrea, y con el antecedente de 2 cesáreas. Se le realizó un legrado uterino que se complicó y terminó en la realización de una histerectomía. El embarazo ectópico en cicatriz de cesárea es raro, sin embargo, es importante pensar en esta opción diagnóstica en gestantes con sangrado en el primer trimestre con antecedente de cesárea para poder buscar signos ecográficos en la evaluación.
Extrauterine gestation is called ectopic pregnancy, this is an obstetric emergency of the first trimester, which is having an increasing incidence. One of the locations in which these pregnancies can be generated is the scar from a previous cesarean section, which is a challenge for the treating gynecologist due to its diagnostic difficulty and therapeutic options. We report the case of a 37-year-old patient who was admitted to the emergency service with 6 weeks of amenorrhea, and with a history of 2 cesarean sections. She underwent a uterine curettage that was complicated and ended in a hysterectomy. Ectopic pregnancy in cesarean section scar is rare, however, it is important to consider this diagnostic option in pregnant women with bleeding in the first trimester with a history of cesarean section to be able to look for ultrasound signs in the evaluation.
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El embrión, en condiciones normales, es concebido en la trompa y migra al útero. Un pequeño porcentaje que no llega a completar esta migración, se convierte en embarazo ectópico. Se presentó el caso de un embarazo ectópico abdominal con feto vivo; paciente femenina de 32 años de edad, multigesta con 4 partos eutócicos a término. A las 37 semanas de edad gestacional se remitió al Hospital Provincial de Bié por presentar dolor abdominal difuso, de moderada intensidad, que se exacerbaba con los movimientos fetales. Se realizó la cesárea, se encontró un embarazo ectópico abdominal con feto vivo y placenta implantada en fondo uterino, epiplón y colon transverso. Se dejó placenta in situ para un posterior seguimiento.
The embryo, under normal conditions, is conceived into the fallopian tube and migrates to the uterus. A small percentage of the embryos that do not complete this migration become an ectopic pregnancy. We present a 32-year-old female patient with multiple gestation pregnancies and 4 normal term deliveries who had an abdominal ectopic pregnancy with a live fetus. She was referred to Bié Provincial Hospital at 37 weeks' gestation due to diffuse abdominal pain of moderate intensity, which was exacerbated by fetal movements. A cesarean section was performed; an abdominal ectopic pregnancy with a live fetus and the placenta implanted in the uterine fundus, omentum, and transverse colon was found. The placenta was left in situ for further follow-up.
Subject(s)
Pregnancy, Abdominal , Pregnancy, Ectopic , Cesarean SectionABSTRACT
Objective:To observe the clinical outcomes of continued pregnancy in pregnant women with cesarean scar pregnancy (CSP).Methods:A retrospective analysis was performed on the pregnancy outcomes of 55 pregnant women who were diagnosed with CSP at the Second Affiliated Hospital of Army Medical University during the first trimester of pregnancy from August 1st, 2018 to October 31st, 2021 and strongly requested to continue the pregnancy.Results:Of the 55 pregnant women, 15 terminated the pregnancy in the first trimester, 1 underwent hysterotomy at 23 weeks of gestation due to cervical dilation, and 39 (71%, 39/55) continued pregnancy to the third trimester achieving live births via cesarean section. The gestational age of the 39 pregnant women delivered by cesarean section was 35 +6 weeks (range: 28 +5-39 +2 weeks), of whom 7 cases at 28 +5-33 +6 weeks, 20 cases at 34-36 +6 weeks, and 12 cases at 37-39 +2 weeks. The results of pathological examination were normal placenta in 3 cases (8%, 3/39), placenta creta in 4 cases (10%, 4/39), placenta increta in 9 cases (23%, 9/39) and placenta percreta in 23 cases (59%, 23/39). Among the 36 pregnant women who were pathologically confirmed as placenta accreta spectrum disorders (PAS) after surgery, the last prenatal ultrasonography showed placenta previa in 27 cases (75%, 27/36) and not observed placenta previa in 9 cases. The median intraoperative blood loss, autologous blood transfusion, and allogeneic suspended red blood cell infusion of 39 pregnant women during cesarean section were 1 000 ml (300-3 500 ml), 300 ml (0-2 000 ml) and 400 ml (0-2 400 ml), respectively. The uterine preservation rate was 100% (39/39), and only 1 case received cystostomy due to intracystic hemorrhage. The birth weight of the newborn was 2 580 g (1 350-3 800 g), and 1 case of mild asphyxia. Conclusions:Pregnant women with CSP who continue pregnancy under close monitoring after adequate ultrasound evaluation and doctor-patient communication could achieve better maternal and infant outcomes, but pregnant women with CSP are highly likely to continue pregnancy and develop into PAS. Effective hemostasis means and multidisciplinary team cooperation are needed in perinatal period for ensuring maternal and fetal safety.
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Objective:To investigate the clinical value of transabdominal ultrasonography versus transvaginal ultrasonography in the early diagnosis of ectopic pregnancy. Methods:A total of 100 patients with suspected early ectopic pregnancy who received treatment in Luanping Shengjian Hospital between April 2019 and April 2021 were included in this study. All of them underwent transabdominal and transvaginal ultrasonography. Surgical pathological results were used as the gold standard to analyze the diagnostic efficacy of the two examination methods. The detection rate of ectopic pregnancy by ultrasonography was compared between the two examination methods.Results:Early ectopic pregnancy was detected in 59 cases by transabdominal ultrasonography, among which seven cases were misdiagnosed and 10 cases were missed. Early ectopic pregnancy was detected in 60 cases by transvaginal ultrasonography, among which one case was misdiagnosed and three cases were missed. The sensitivity, specificity and accuracy of transvaginal ultrasonography in the early detection of ectopic pregnancy were 95.2%, 97.4% and 96.0%, respectively, which were significantly higher than those of transabdominal ultrasonography (83.9%, 81.6%, 83.0%, χ2 =4.21, 5.03, 8.99, P = 0.040, 0.025, 0.003). Transvaginal ultrasonography showed that detection rates of accessory mass, yolk sac, embryo, intrauterine pseudopregnancy sac, pelvic effusion and original vascular fluctuation were 88.7%, 50.0%, 24.2%, 22.6%, 12.9%, 87.1%, respectively, which were significantly higher than those of transabdominal ultrasonography (64.5%, 19.4%, 4.8%, 4.8%, 1.6%, 56.5%, χ2 = 10.13, 12.85, 9.36, 8.25, 5.87, 14.37, P = 0.001, < 0.001, = 0.002, = 0.004, = 0.015, < 0.001). Conclusion:Transvaginal ultrasonography is superior to transabdominal ultrasonography in the early detection of ectopic pregnancy and has a higher detection rate of sonographic manifestation than transabdominal ultrasonography.
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Resumen OBJETIVO: Describir la experiencia en la atención de pacientes con embarazo ectópico no complicado con una inyección local de metotrexato guiada por ecografía. MATERIALES Y MÉTODOS: Estudio retrospectivo, descriptivo y de serie de casos llevado a cabo del 1 de enero del 2021 al 28 de febrero del 2022 en el Instituto Nacional Materno Perinatal, Lima, Perú. Las participantes tuvieron embarazo ectópico no complicado, tratado con inyección local de metotrexato guiada por ecografía. Los datos se obtuvieron de los registros en las historias clínicas. El análisis estadístico se procesó en el programa SPSS 19. RESULTADOS: Se registraron 222 casos de embarazo ectópico y se aplicaron 11 inyecciones locales con metotrexato guiadas por ecografía. De acuerdo con su localización 4 embarazos fueron tubáricos, 1 cervical y 6 en cicatriz de cesárea. La edad promedio de las embarazadas fue de 34.5 años. El promedio de semanas de embarazo fue de 7. La concentración inicial de b-hCG fue de 42812.55 mU/mL. El tamaño promedio del saco gestacional fue de 22.8 mm. El tamaño medio de los embriones fue de 7.81 mm. Se detectó actividad cardiaca embrionaria en 10 casos que recibieron una inyección intratorácica de cloruro de potasio hasta que no se evidenció el latido cardiaco. Un solo caso recibió una dosis sistémica adicional de metotrexato. Otro caso resultó con hemoperitoneo, por rotura de embarazo ectópico luego de la inyección local. CONCLUSIONES: La inyección local de metotrexato, guiada por ecografía, es una alternativa a otras técnicas quirúrgicas aplicadas para tratar pacientes con embarazo ectópico no complicado, con indicación quirúrgica.
Abstract OBJECTIVE: To describe the experience in the care of patients with uncomplicated ectopic pregnancy with ultrasound-guided local injection of methotrexate. MATERIALS AND METHODS: Retrospective, descriptive, case series study conducted from January 1, 2021 to February 28, 2022 at the Instituto Nacional Materno Perinatal, Lima, Peru. Participants had uncomplicated ectopic pregnancy treated with ultrasound-guided local injection of methotrexate. Data were obtained from medical records. Statistical analysis was processed in SPSS 19. RESULTS: 11 ultrasound-guided local methotrexate injections were performed. According to their location 4 pregnancies were tubal, 1 cervical and 6 in cesarean scar. The average age of the pregnant women was 34.5 years. The average number of weeks of pregnancy was 7. The initial b-hCG concentration was 42812.55 mU/mL. The mean gestational sac size was 22.8 mm. The mean embryo size was 7.81 mm. Embryonic cardiac activity was detected in 10 cases that received an intrathoracic injection of potassium chloride until no heartbeat was evident. A single case received an additional systemic dose of methotrexate. Another case resulted in hemoperitoneum, due to rupture of ectopic pregnancy after local injection. CONCLUSIONS: Ultrasound-guided local injection of methotrexate is an alternative to other surgical techniques applied to treat patients with uncomplicated ectopic pregnancy with surgical indication.
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Objective:To investigate the clinical effect of focused ultrasound ablation surgery (FUAS) combined with suction curettage for mass-type cesarean scar pregnancy (CSP) and to analyze the influencing factors of vaginal bleeding and readmission.Methods:From January 2014 to December 2020, 88 patients with mass-type CSP were treated by FUAS combined with suction curettage in the Third Xiangya Hospital of Central South University. The clinical results and the influencing factors of bleeding and readmission for mass-type CSP were analyzed.Results:All the patients underwent one time FUAS treatment successfully. Immediately after FUAS treatment, color Doppler ultrasound showed obvious necrosis and no perfusion area in all lesions, and the blood flow in the mass-type CSP tissue significantly decreased. The median volume of blood loss in the procedure was 20 ml (range: 5-950 ml). Thirteen patients (15%, 13/88) had vaginal bleeding≥200 ml, and 15 patients (17%, 15/88) were hospitalized again. The average time for menstruation recovery was (28±8) days (range: 18-66 days). The average time needed for serum human chorionic gonadotropin-beta subunit to return to normal levels was (22±6) days (range: 7-59 days). The risk of large vaginal bleeding of patients were related to the blood supply of the mass ( OR=5.280, 95% CI: 1.335-20.858, P=0.018) and the largest diameter of the mass ( OR=1.060, 95% CI: 1.010-1.120, P=0.030). The risk of readmission were related to the largest diameter of the mass ( OR=1.055, 95% CI: 1.005-1.108, P=0.030) and the depth of the uterus cavity ( OR=1.583, 95% CI: 1.015-2.471, P=0.043). No serious complications such as intestinal and nerve injury occurred during and after FUAS treatment. Conclusions:FUAS combined with suction curettage is safe and effective in treating patients with mass-type CSP through this preliminary study. The volume of vaginal bleeding are associated with the blood supply of the mass and the largest diameter of the mass, the risk of readmission are related to the largest diameter of the mass and the depth of the uterus cavity.
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Ectopic pregnancy is one of the most common acute abdominal diseases in gynecology. A ruptured ectopic pregnancy can lead to hemorrhagic shock, which is life-threatening. Therefore, early diagnosis and early treatment are extremely critical for preserving fertility and achieving good prognosis in patients with ectopic pregnancy. The available diagnostic methods of ectopic pregnancy include laboratory tests such as progesterone test, human chorionic gonadotropin test and ultrasound examination. Ultrasound examination can help determine the location of uterine and adnexal masses, gestational sacs, and germ, all of which are directly related to the final diagnosis regarding ectopic pregnancy. Ultrasound examination includes abdominal ultrasound and transvaginal ultrasound. Transvaginal ultrasound accesses to the focal tissue closer than abdominal ultrasound, and it does not require a full bladder. These advantages make clinical practice of transvaginal ultrasound easier for both physicians and patients. However, application of transvaginal ultrasound in the diagnosis of ectopic pregnancy requires further investigation to guide the early diagnosis and treatment of ectopic pregnancy. .
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A gestação ectópica em cicatriz de cesariana prévia é um evento iatrogênico raro, que vem crescendo junto com o aumento das taxas de cesariana. Ela não exi- be manifestação clínica específica, o que dificulta o diagnóstico e não apresenta tratamento preconizado, embora esteja associada a grandes complicações obsté- tricas como hemorragia incoercível, acretismo placentário e rotura uterina. Dessa forma, o presente artigo relata três casos clínicos em que diferentes tratamentos foram propostos, objetivando discutir algumas possibilidades terapêuticas como a aspiração manual intrauterina (AMIU) associada com o uso de metotrexato, lapa- roscopia e laparotomia, comparando os resultados encontrados.(AU)
Ectopic cesarean scar pregnancy is a rare iatrogenic event, which has been increase with growing in the percentage of cesarean delivery. It does not exhibit specific cli- nical manifestation, making diagnosis difficult and does not have yet recommended treatment, although is associated with major obstetrics complication such incoer- cible hemorrhage, abnormally invasive placenta and uterine rupture. Therefore, the present article reports three clinical cases witch different types of management, ai- ming discuss some possibilities such intrauterine manual aspiration after systemic methotrexate, laparoscopy or laparotomy surgical, comparing results.(AU)
Subject(s)
Humans , Female , Pregnancy , Pregnancy, Ectopic/surgery , Cesarean Section/adverse effects , Suction , Cicatrix , Video-Assisted Surgery , LaparotomyABSTRACT
O tema doença inflamatória pélvica está contemplado no Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis, publicado pelo Ministério da Saúde do Brasil em 2020. A doença inflamatória pélvica é a infecção aguda do trato genital superior feminino decorrente da ascensão canalicular de microrganismos cervicovaginais endógenos e, principalmente, os de transmissão sexual. Entre os agentes etiológicos envolvidos, destacam-se Chlamydia trachomatis e Neisseria gonorrhoeae. As sequelas mais importantes são dor pélvica crônica, infertilidade e gravidez ectópica. O diagnóstico clínico apresenta-se como a abordagem prática mais importante. O tratamento com antibióticos deve ser iniciado imediatamente diante da suspeição clínica. Descrevem-se orientações para gestores e profissionais de saúde sobre testes diagnósticos, tratamento preconizado, seguimento, aconselhamento, notificação, manejo de parcerias sexuais e de populações especiais. Com a maior disponibilidade da técnica de biologia molecular no Brasil, recomenda-se o rastreio de C. trachomatis e N. gonorrhoeae como estratégia preventiva da doença.
Pelvic Inflammatory Disease is a topic included in the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. Pelvic inflammatory disease is an acute infection of the upper female genital tract due to canalicular spread of endogenous cervicovaginal microorganisms, in particular sexually transmitted organisms. Standing out among the etiological agents involved are Chlamydia trachomatis and Neisseria gonorrhoeae. The most important sequels are chronic pelvic pain, infertility and ectopic pregnancy. Clinical diagnosis is the most important practical approach. Antibiotic treatment should start immediately upon clinical suspicion. The article contains guidance for health service managers and health professionals on diagnostic tests, treatment, follow-up, counseling, notification, handling of sexual partnerships and special populations. In view of increased availability of the molecular biology technique in Brazil, C. trachomatis and N. gonorrhoeae screening is recommended as a disease prevention strategy.
El tema de la enfermedad inflamatoria pélvica está incluido en el Protocolo Clínico y Directrices Terapéuticas para la Atención Integral para Personas con Infecciones de Transmisión Sexual, publicado por el Ministerio de Salud de Brasil en 2020. La enfermedad inflamatoria pélvica es una infección aguda del tracto genital superior femenino resultante del ascenso canalicular de microorganismos cervicovaginales endógenos y, principalmente, los de transmisión sexual. Entre los agentes etiológicos involucrados, se destacan Chlamydia trachomatis y Neisseria gonorrhoeae. Las secuelas más importantes son: dolor pélvico crónico, infertilidad y embarazo ectópico. El diagnóstico clínico es el enfoque práctico más importante. El tratamiento con antibiótico debe iniciarse inmediatamente ante la sospecha clínica. Se describen pautas para gestores y profesionales de la salud sobre pruebas de diagnóstico, tratamiento, seguimiento, asesoramiento, notificación, manejo de parejas sexuales y poblaciones especiales. Con la mayor disponibilidad de la técnica de biología molecular, se recomienda el cribado de C. trachomatis y N. gonorrhoeae como estrategia preventiva para la enfermedad.
Subject(s)
Humans , Female , Pregnancy , Sexually Transmitted Diseases/epidemiology , Pelvic Inflammatory Disease/diagnosis , Pelvic Inflammatory Disease/therapy , Pelvic Inflammatory Disease/epidemiology , Sexual Behavior , Brazil/epidemiology , Chlamydia trachomatis/pathogenicity , Clinical Protocols , Neisseria gonorrhoeae/pathogenicityABSTRACT
Resumo O tema doença inflamatória pélvica está contemplado no Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis, publicado pelo Ministério da Saúde do Brasil em 2020. A doença inflamatória pélvica é a infecção aguda do trato genital superior feminino decorrente da ascensão canalicular de microrganismos cervicovaginais endógenos e, principalmente, os de transmissão sexual. Entre os agentes etiológicos envolvidos, destacam-se Chlamydia trachomatis e Neisseria gonorrhoeae. As sequelas mais importantes são dor pélvica crônica, infertilidade e gravidez ectópica. O diagnóstico clínico apresenta-se como a abordagem prática mais importante. O tratamento com antibióticos deve ser iniciado imediatamente diante da suspeição clínica. Descrevem-se orientações para gestores e profissionais de saúde sobre testes diagnósticos, tratamento preconizado, seguimento, aconselhamento, notificação, manejo de parcerias sexuais e de populações especiais. Com a maior disponibilidade da técnica de biologia molecular no Brasil, recomenda-se o rastreio de C. trachomatis e N. gonorrhoeae como estratégia preventiva da doença.
Abstract Pelvic Inflammatory Disease is a topic included in the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. Pelvic inflammatory disease is an acute infection of the upper female genital tract due to canalicular spread of endogenous cervicovaginal microorganisms, in particular sexually transmitted organisms. Standing out among the etiological agents involved are Chlamydia trachomatis and Neisseria gonorrhoeae. The most important sequels are chronic pelvic pain, infertility and ectopic pregnancy. Clinical diagnosis is the most important practical approach. Antibiotic treatment should start immediately upon clinical suspicion. The article contains guidance for health service managers and health professionals on diagnostic tests, treatment, follow-up, counseling, notification, handling of sexual partnerships and special populations. In view of increased availability of the molecular biology technique in Brazil, C. trachomatis and N. gonorrhoeae screening is recommended as a disease prevention strategy.
Resumen El tema de la enfermedad inflamatoria pélvica está incluido en el Protocolo Clínico y Directrices Terapéuticas para la Atención Integral para Personas con Infecciones de Transmisión Sexual, publicado por el Ministerio de Salud de Brasil en 2020. La enfermedad inflamatoria pélvica es una infección aguda del tracto genital superior femenino resultante del ascenso canalicular de microorganismos cervicovaginales endógenos y, principalmente, los de transmisión sexual. Entre los agentes etiológicos involucrados, se destacan Chlamydia trachomatis y Neisseria gonorrhoeae. Las secuelas más importantes son: dolor pélvico crónico, infertilidad y embarazo ectópico. El diagnóstico clínico es el enfoque práctico más importante. El tratamiento con antibiótico debe iniciarse inmediatamente ante la sospecha clínica. Se describen pautas para gestores y profesionales de la salud sobre pruebas de diagnóstico, tratamiento, seguimiento, asesoramiento, notificación, manejo de parejas sexuales y poblaciones especiales. Con la mayor disponibilidad de la técnica de biología molecular, se recomienda el cribado de C. trachomatis y N. gonorrhoeae como estrategia preventiva para la enfermedad.
Subject(s)
Female , Humans , Pregnancy , Sexually Transmitted Diseases , Pelvic Inflammatory Disease , Sexual Behavior , Brazil , Sexually Transmitted Diseases/diagnosis , Sexually Transmitted Diseases/prevention & control , Sexually Transmitted Diseases/epidemiology , Chlamydia trachomatis , Pelvic Inflammatory Disease/diagnosis , Pelvic Inflammatory Disease/therapy , Pelvic Inflammatory Disease/epidemiologyABSTRACT
Objective:To study the clinical characteristics of cornual pregnancy and compare the effects of various surgical methods on the outcomes.Methods:This was a single-center retrospective study. The clinical records of patients with cornual pregnancy who underwent surgery in Peking Union Medical College Hospital from June 2012 to December 2020 were collected. Surgical interventions included curettage (guided by ultrasound or monitored by laparoscope), and cornuostomy/cornectomy (the surgical approach by laparoscopy or laparotomy). The baseline data, perioperative treatment and whether persistent ectopic pregnancy (PEP) occurred after surgery were collected and analyzed statistically.Results:A total of 109 patients with cornual pregnancy diagnosed by surgical treatment were included in this study, whose average age was (32.9±4.8) years. Among them, the incidence of postoperative PEP was 16.5% (18/109). The risk of PEP in multipara was significantly higher than that in nulliparous women ( OR=7.639, 95% CI: 2.063-28.279, P=0.001). The risk of PEP in patients with the maximum diameter of lesion<1.5 cm was significantly higher than that in patients with the maximum diameter of lesion≥1.5 cm ( OR=8.600, 95% CI: 2.271-32.571, P=0.002). Among all surgical approaches for cornual pregnancy, the proportion of PEP in curettage under ultrasound monitoring was the highest (56.0%, 14/25), which was higher than that in curettage under laparoscope monitoring (1/10; χ2=6.172， P=0.013); the proportion of PEP in curettage group (42.9%, 15/35) was higher than that in cornuostomy/cornectomy group (4.1%, 3/74; χ2=25.950， P<0.01). Neither salpingectomy in the operation nor the routine use of methotrexate (MTX) in perioperative period could significantly reduce the incidence of PEP (all P>0.05). Conclusions:Among the patients with cornual pregnancy, multipara, the maximum diameter of lesion<1.5 cm and ultrasound-guided curettage are the risk factors of PEP after operation. Cornuostomy or cornectomy is recommended for patients with cornual pregnancy. If the patients would perform the curettage operation, laparoscopic monitoring is recommended. For patients with possible satisfactory operation outcome, it is not recommended to use MTX as a routine preventing measure.
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Objective:To study the risk factors of adverse pregnancy outcomes for induced abortion of cesarean scar pregnancy in midtrimester.Methods:A national multicenter retrospective study was conducted. A total of 154 singletons pregnant women with cesarean scar pregnancy during the second trimester induced abortion by various reasons in 12 tertiary A hospitals were selected, their pregnant outcomes were observed and the risk factors of serious adverse outcomes were analyzed with univariate and multivariate logstic regression; the role of ultrasound and MRI in predicting placenta accreta and severe adverse outcomes was evaluated, the effectiveness of uterine artery embolization (UAE) in preventing hemorrhage in pregnant women with and without placenta accreta was compared.Results:Among 154 subjects, the rate of placenta accreta was 42.2% (65/154), the rate of postpartum hemorrhage≥1 000 ml was 39.0% (60/154), the rate of hysterectomy was 14.9% (23/154), the rate of uterine rupture was 0.6% (1/154). The risk factor of postpartum hemorrhage≥1 000 ml and hysterectomy was placenta accreta ( P<0.01). For each increase in the number of parity, the risk of placenta accreta increased 2.385 times (95% CI: 1.046-5.439; P=0.039); and the risk of placenta accreta decreased with increasing ultrasound measurement of scar myometrium thickness ( OR=0.033, 95% CI: 0.001-0.762; P=0.033). The amount of postpartum hemorrhage and hysterectomy rate in the group with placenta accreta diagnosed by ultrasound combined with MRI were not significantly different from those in the group with placenta accreta diagnosed by ultrasound only or MRI only (all P>0.05). For pregnant women with placenta accreta, there were no significant difference in the amount of bleeding and hysterectomy rate between the UAE group [median: 1 300 ml; 34% (16/47)] and the non-embolization group (all P>0.05); in pregnant women without placenta accreta, the amount of bleeding in the UAE group was lower than that in the non-embolization group (median: 100 vs 600 ml; P<0.01), but there was no significant difference in hysterectomy rate [2% (1/56) vs 9% (3/33); P>0.05]. Conclusions:(1) Placenta accreta is the only risk factor of postpartum hemorrhage≥1 000 ml with hysterectomy for induced abortion of cesarean scar pregnancy in midtrimester; multi-parity and ultrasound measurement of scar myometrium thickness are risk factors for placenta accreta. (2) The technique of using ultrasound and MRI in predicting placenta accreta of cesarean scar pregnancy needs to be improved. (3) It is necessary to discuss of UAE in preventing postpartum hemorrhage for induced abortion of cesarean scar pregnancy in midtrimester.
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Objective:To compare surgical methods and clinical efficacy among different types of cesarean scar pregnancy (CSP).Methods:A total of 158 patients with CSP who received treatment in Yuncheng Central Hospital from January 2016 to June 2019 were included in this study. According to Expert Consensus on Diagnosis and Treatment of Cesarean Scar Pregnancy (2016 version), type I CSP was found in 55 patients, type II in 86 patients and type III in 17 patients. These patients were divided into groups A (ultrasound-guided suction curettage), B (uterine artery chemoembolization + ultrasound-guided suction curettage) and C (laparoscopic scar pregnancy lesion resection + scar repair) according to different surgical methods. The amount of intraoperative blood loss, the difference in human chorionic gonadotropin (HCG) level between before and after surgery, the time to postoperative HCG level returning to normal level, menstruation recovery, and re-pregnancy were compared between groups.Results:The amount of intraoperative blood loss in the groups A, B and C was (43.33 ± 72.31) mL, (34.41 ± 17.16) mL, (65.71 ± 70.52) mL, respectively. There was significant difference between groups ( F = 8.51, P = 0.014]. The difference in HCG level between before and after surgery in groups A, B and C was (0.64 ± 0.18), (0.79 ± 0.10), (0.76 ± 0.19), respectively. There was significant difference in the difference in HCG level between groups ( F = 19.21, P < 0.001). There was significant difference in the incidence of postoperative menstrual volume reduction between group B and the other two groups ( χ2 = 6.73, P = 0.003). After surgery, intrauterine pregnancy occurred in 12 patients, including 8 patients in group A (type I CSP in 2 patients, type II CSP in 3 patients, type III CSP in 3 patients), 4 patients in group B (type I CSP in 3 patients, type II CSP in 1 patient). Finally, full-term fetus delivery by cesarean section was performed in 6 patients (4 patients in group A and 2 patients in group B). Conclusion:Uterine artery chemoembolization combined with uterine curettage had less blood loss, during surgery and leads to an obvious decrease in HCG level, but it can result in reduction of menstrual volume. Ultrasound-guided suction curettage is preferred for type I and type II CSP. Balloon compression can be used to stop bleeding if massive bleeding occurs. Laparoscopic scar pregnancy lesion resection plus scar repair is recommended for type III CSP.
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Antecedentes. El embarazo ectópico cervical es la implantación del embrión en la zona de revestimiento del canal endocervical. Representa menos del 1% de todos los embarazos ectópicos. Reporte de Caso: Reportamos dos pacientes que acuden a consulta de emergencia por sangrado transvaginal. El diagnóstico de embarazo ectópico cervical fue realizado por ecografía transvaginal (7 y 8 semanas de gestación). Se inició tratamiento con metotrexato (paciente de 28 años) y metotrexato-ácido folínico (paciente de 35 años). Debido al aumento de la hormona gonadotropina coriónica humana se decidió realizar una histerectomía abdominal (paciente de 28 años) y curetaje-cerclaje cervical tipo McDonald (paciente de 35 años). No hubo complicaciones posteriores a la cirugía en ambas pacientes. Conclusiones: El tratamiento del embarazo ectópico cervical es controversial. Se debe elegir la terapia más apropiada para preservar la fertilidad y evitar complicaciones como la hemorragia.
Background. Cervical ectopic pregnancy is the implantation of the embryo in the lining of the endocervical canal lining. It represents less than 1% of all ectopic pregnancies. Case description: We report two patients who come to the emergency room for transvaginal bleeding. The diagnosis of cervical ectopic pregnancy was made by transvaginal ultrasound (7- and 8-weeks' gestation). Treatment was started with methotrexate (28-year-old patient) and methotrexatefolinic acid (35-year-old patient). Due to the increase in human chorionic gonadotropin hormone, it was decided to perform an abdominal hysterectomy (28-year-old patient) and McDonald-type cervical curettagecerclage (35-year-old patient). There were no complications after surgery in both patients. Conclusions: The treatment of cervical ectopic pregnancy is controversial. The most appropriate therapy should be chosen to preserve fertility and avoid complications such as bleeding.
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Ectopic pregnancy occurs when the fertilized ovum implantation happens outside the uterus, and it is not rarely associated with maternal death. Tubal ectopic pregnancy is the most common form of ectopic pregnancy and the bilateral form is very rare. Performing an early diagnosis is difficult in most cases and if usually happens during surgery. The purpose of this paper is to describe a case of spontaneous bilateral tubal ectopic pregnancy and its particularities.
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Objective: To explore the effect and impact factors of prophylactic uterine artery embolization (UAE) for reducing bleeding during curettage in treatment of cesarean scar pregnancy (CSP). Methods: Data of 841 CSP patients who underwent prophylactic UAE and uterine curettage were retrospectively analyzed. The volume of blood loss during uterine curettage was evaluated, ≥200 ml was judged as poor hemostasis. The influencingmpact factors of poor hemostatic effectsis were analyzed, and complications within 60 days after operation were calculated. Results: Among 841 patients, volume of blood loss during uterine curettage was found ≥200 ml in 53 patients, parity, and embolic agent diameter (>1 000 μm), multi-vessel blood supply and incomplete embolization were independent risk factors (all P<0.05). Within 60 days after UAE, the main postoperative complications included abdominal pain, low fever, nausea and vomiting, and buttock pain, with incidence rates of 71.22% (599/841), 47.44% (399/841), 39.12% (329/841) and 36.39% (306/841), respectively. Conclusion: Prophylactic UAE before uterine curettage in patients with CSP is safe and effective to reduce intraoperative bleeding, and parity, embolic agent diameter, multivessel blood supply as well as incomplete embolization are impact factors.
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Objective@#To explore the application value of B-ultrasound examination in gynecological acute abdomen.@*Methods@#From October 2015 to October 2017, 150 patients with suspected gynecological acute abdomen were selected in the People's Hospital of Lishui.The effect of B-ultrasound examination in diagnosis of gynecological acute abdomen was analyzed.@*Results@#The sensitivity, specificity and total accuracy of abdominal ultrasound in the diagnosis of gynecological acute abdomen were 75.00%(99/132), 44.44%(8/18) and 71.33%(107/150), respectively.The sensitivity, specificity and total accuracy of transvaginal ultrasound in the diagnosis of gynecological acute abdomen were 87.12%(115/132), 72.22%(13/18) and 85.33%(128/150), respectively.The sensitivity, specificity and total accuracy of abdominal combined with transvaginal ultrasonography in the diagnosis of gynecological acute abdomen were 98.48%(130/132), 94.44%(17/18) and 98.00%(147/150), respectively.The sensitivity, specificity and total accuracy of abdominal combined with transvaginal ultrasound in the diagnosis of gynecological acute abdomen were significantly higher than those of abdominal ultrasound and transvaginal ultrasound(χ2=8.658, 10.699, 9.075, all P<0.05). The diagnosis of acute pelvic inflammation, ectopic pregnancy, rupture of luteal cyst and torsion of ovarian cyst by abdominal combined with transvaginal ultrasound was better than abdominal ultrasound(χ2=13.748, 5.984, 13.524, 6.874, all P<0.05).@*Conclusion@#Abdominal ultrasound and transvaginal ultrasound can be used to diagnose gynecological acute abdomen.However, abdominal combined with vaginal ultrasound is more effective in the diagnosis of gynecological acute abdomen, and it can effectively improve the accuracy of diagnosis.
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Objective@#To investigate the clinical efficacy of uterine arterial embolization combined with hysteroscopy in the treatment of cesarean scar pregnancy.@*Methods@#From September 2016 to March 2018, 68 patients with cesarean scar pregnancy in the People's Hospital of He'nan Province were collected.According to different treatment methods, the patients were divided into observation group and control group.The observation group (42 cases) firstly received bilateral uterine artery embolization, then hysteroscopy pregnancy lesion was resected after 2-3 days.The control group (26 cases) directly received hysteroscopy endoscopic pregnancy lesion resection.@*Results@#There were 42 cases in the observation group, 2 cases(all of them III type)failed, of which 1 case was treated with laparoscopy, and 1 case was converted to transvaginal focus clearance.In the control group, 26 cases of cesarean scar pregnancy were treated directly by hysteroscopy, and 6 cases were failed(1 case of type I, 4 cases of type II, 1 case of type III), among which 3 cases were treated with uterine artery embolization.Then hysteroscopic surgery was performed in 2 cases, combined with laparoscopy for pregnancy focus debridement.One case of severe hemorrhage occurred in III type operation, which was immediately converted to open operation.The operation time, intraoperative blood loss, surgical success rate, length of hospital stay, blood β-HCG return to normal time, menstrual recovery time, postoperative vaginal bleeding, postoperative vaginal bleeding time in the observation group were (17.09±3.62)min, (32.6±5.6)mL, 95.2%(40/42), (4.76±1.63)d, (18.00±6.62)d, (30.28±4.23)d, (32.75±8.32)mL, (3.26±1.06)d, respectively, which in the control group were (49.51±3.41)min, (60.3±13.6)mL, 76.9%(20/26), (7.23±1.96)d, (22.00±6.91)d, (36.41±7.62)d, (46.23±11.73)mL, (6.42±2.45)d, respectively, the differences between the two groups were statistically significant(t=36.68, 14.09, χ2=5.189, t=5.62, 2.30, 4.27, 5.54, 7.35, all P<0.05).@*Conclusion@#Bilateral uterine artery embolization combined with hysteroscopy in the treatment of cesarean scar pregnancy has some advantages including high successful rate, short operation time, less bleeding, hospitalization time and postoperative recovery, etc.It is a safe and effective treatment especially for type I and type II scar pregnancy.
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RESUMEN Introducción: el embarazo ectópico abdominal es una anomalía excepcional que representa el 1 % de los embarazos ectópicos; se asocia con alta morbilidad y mortalidad materna y fetal. El riesgo de mortalidad materna es de siete a ocho veces mayor que el de un embarazo ectópico tubario y 90 veces mayor que el de un embarazo intrauterino. Presentación del caso: paciente angolana adulta joven con un embarazo ectópico abdominal diagnosticado al término del embarazo. Se trató con éxito mediante cesárea con extracción del feto vivo y sin complicaciones. No se extrajo la placenta por encontrarse implantada al Meso intestinal y se aplicó tratamiento con metrotexate posterior a la intervención quirúrgica. Conclusiones: el embarazo abdominal es una enfermedad de difícil diagnóstico a pesar de los avances tecnológicos. Por lo que el sistema de salud debe establecer estrategias y programas educativos accesibles, dirigidos a la población femenina que tengan sospecha de embarazo ectópico. Una vez diagnosticado el embarazo abdominal, debe interrumpirse, a menos que la edad de gestación sea avanzada. El manejo de la placenta debe ser individualizado.
ABSTRACT Introduction: abdominal ectopic pregnancy is an exceptional abnormality representing 1% of ectopic pregnancies; it is associated with high maternal and fetal morbidity and mortality. The risk of maternal mortality is seven to eight times greater than a tubal ectopic pregnancy and 90 times greater than an intrauterine pregnancy. Case report: young adult Angolan patient with an ectopic abdominal pregnancy diagnosed at the end of pregnancy; successfully treated by caesarean section with live, uncomplicated extraction of the fetus. Removal of the placenta was not attempted as it was implanted in the mesointestinal structure; undergoing treatment with methotrexate after the surgery. Conclusions: abdominal pregnancy is a complex disease to be diagnosed despite technological advances. Therefore, the health system must establish accessible educational strategies and programs aimed at taking care of female population suspected of ectopic pregnancy. Once an abdominal pregnancy has been diagnosed, it should be interrupted, except the gestational age is advanced. The management of the placenta should be individualized.
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@#：【Objective】Toprovidefurtherevidenceoftheassociationbetweencesareanscarpregnancy（CSP）and placentaincreta，andtoinvestigatetheriskofexpectantmanagementofCSP.【Methods】Aretrospectivereviewof3women diagnosedwithCSP，whoweremanagedexpectantly，wasperformedintheThirdAffiliatedHospitalofSUNYat-sen UniversityfromJanuary2014toDecember2018.Theirclinicalcharacteristics，sonographicmanifestationandpoorout⁃ comeswereanalyzed.【Results】These3casesofCSPhad1~2previouslowersegmentcesareansectionsandtheirclinical symptomsincludedrecurrenthemorrhage，grosshematuriaandsevereabdominalpain.Amongthe3cases，thegestational ageatdiagnosisofCSPwas6+2weeks，7weeksand7+4weeks，respectively；thesonographicCSPtypewastypeⅠ，type ⅡandtypeⅢ，respectively；thegestationalageatthefirstdiagnosisofplacentaincretawas24+4weeks，12+2weeksand 13+1weeks，respectively；andall3caseswerediagnosedasplacentapercretabyultrasoundatthesecondtrimester.These 3casesofCSPwereterminatedatthesecondtrimesterwithoutlivebornneonatesbecauseofseverehemorrhage，colt tamponadeofbladderanduterinerupture；andallwereconfirmedasplacentapercretaduringsurgerywiththetotalblood lossofmorethan2500mLandwithoutmaternaldeath，andonegotapathologicaldiagnosisofplacentapercretaafter subtotal hysterectomy.【Conclusion】Placenta percreta should be noticed during the expectant management of CSP becauseof the close association between CSP and placenta increta. Natural history of CSP is usually associated with adverseoutcome，andthereforeexpectantmanagementofCSPshouldbecarefullychosen