Cornual or Interstitial Ectopic Pregnancy?

Min et al, mentioned in their published article that the cornual pregnancy is a rare ectopic pregnancy form which occurs in the upper lateral part portion of the uterus, and their studied cornual pregnancy cases were diagnosed at mean gestational age of 8 weeks and 6 days (7 cases of ruptured cornual pregnancies, and 41 cases of non-ruptured cornual pregnancies). The published Min et al, article may be confusing to the readers. William's textbook of Obstetrics defines cornual pregnancy as a pregnancy in a rudimentary horn of the uterus with Müllerian anomaly. Additionally, the cornual pregnancies are usually diagnosed at the mid-trimester of pregnancy 16 weeks for unruptured cornual pregnancies, and 20-21 weeks for ruptured cornual pregnancies.

Intraperitoneally Retained Contraceptive Device After Uterine Perforation: A Case Report.

A 29-year-old parous woman with a history of a T-shaped copper intrauterine device (IUD) insertion presented 8 months later with a complaint of the contraceptive device being missing. Computed tomography with contrast turned out to be superior to the combined abdominal and pelvic X-ray and transvaginal ultrasound in providing the detailed extrauterine location of the device between the urinary bladder and uterus. A laparoscopy was successful in the atraumatic freeing of the IUD from omental and bladder adhesions, and in its final removal.

Treatment of left tubal pregnancy with foetal cardiac activity using a two-dose methotrexate regimen.

The incidence of ectopic pregnancy (EP) is about 1.3-2.4%. Approximately 6% of maternal deaths in the first trimester occur following ruptured EP. A 35-year-old lady, G4, P3, pregnant 7 weeks + 2 days, presented with left iliac pain, after positive pregnancy test, and ß-human chorionic gonadotropin (ß-hCG) 3614 mIU/ml. The transvaginal sonography showed an empty uterus, with a well-defined left adnexal echogenic structure measuring 38×32 mm (left adnexal gestational sac - GS) with foetal pole (bagel sign). The colour Doppler examination showed foetal cardiac activity with circumferential Doppler flow around the GS (ring of fire). She was diagnosed as left undisturbed tubal pregnancy with foetal cardiac activity. She refused the option of laparoscopic surgery. Therefore, she was counselled for medical treatment using methotrexate (MTX). She was also informed that the MTX treatment may fail due to the presence of foetal cardiac activity, and she may need more than one MTX dose. She received the first MTX dose at an initial ß-hCG 3614 mIU/ml. The fourth day ß-hCG after the first MTX dose was 5421 mIU/ml, while the seventh day ß-hCG was 5055 mIU/ml [< 15% decrease of ß-hCG (6.75%)]; therefore, she was given a second MTX dose. The fourth day ß-hCG after the second MTX dose was 3851 mIU/ml, while the seventh day ß-hCG was 2218 mIU/ml [> 15% decrease of ß-hCG (42.4%)]; therefore, she was discharged home for follow-up in the outpatient department. This report represents the treatment of left undisturbed tubal pregnancy with foetal cardiac activity using a two-dose MTX regimen.

Undisturbed tubal pregnancies with positive fetal heart treated medically: Case study.

The incidence of ectopic pregnancy (EP) is 1.3-2.4%. Suspicion of EP starts after a positive serum pregnancy test and failure to visualize the intrauterine gestational sac (GS) by transvaginal sonography (TVS). About 88% of tubal EPs are diagnosed by absent intrauterine GS and the presence of an adnexal mass during TVS. Medical treatment of EP using methotrexate (MTX) is cost-effective with a similar success rate to surgical treatment. The presence of fetal heart beats, ß-human chorionic gonadotropin >5000 mIU/mL, and EP size >4 cm are relative contraindications for using MTX in the treatment of EP.

Ovarian Fibroma Commonly Misdiagnosed as Uterine Leiomyoma.

Ovarian fibroma usually misdiagnosed preoperatively as uterine leiomyoma. A 36-year-old woman, presented with abdominal pain and vomiting, provisionally diagnosed as complicated ovarian cyst. The transvaginal ultrasound and Doppler showed left solid adnexal mass with preserved ovarian blood flow. Magnetic resonance imaging showed a well-defined solid mass in the left side of the pelvis, measuring 8 cm × 10 cm most probably subserous uterine leiomyoma. At laparotomy, the solid ovarian mass was originating from the left ovary, and the microscopic examination confirmed the diagnosis of the ovarian fibroma. This report represents the preoperative misdiagnosis of the ovarian fibromas and the conservative ovarian surgery for the ovarian fibromas and the importance of the follow-up for future fertility and/or recurrence of the fibromas in young women.

Successful Pregnancy Outcome Immediately after Methotrexate Treatment for Cesarean Section Scar Pregnancy.

A 27-year-old cesarean section scar pregnancy (CSSP) case diagnosed by the vaginal ultrasound which showed gestational sac located in the lower uterine anterior quadrant close to the site of the previous scars (with yolk sac inside) with ß-hCG 15,373 mIU/ml in September 2017 was managed by intramuscular (IM) multidose methotrexate (MTX). The studied woman discharged home when the ß-hCG decreased to 11,630 mIU/ml on the 1st week after the first MTX dose. On the 5th week after the first dose of IM-MTX, the ß-hCG dropped to zero and the gestational sac completely disappeared. She was counseled about the risk of pregnancy in the first 6 months after the MTX and the possibility of the CSSP recurrence. She presented on December 16, 2018, with preterm delivery at 35 weeks' gestation. After delivery, her neonate admitted to the neonatal intensive care unit (NICU) due to mild respiratory distress and discharged from the NICU on the 4th day in good condition. Multi-dose MTX regimen for the treatment of CSSP supported by many authors with follow-up by ß-hCG and vaginal ultrasound. This report highlights the successful outcome immediately after the proper management of CSSP cases.

Sentinel Lymph Nodes in Endometrial Cancer Update 2018.

There are no established data about lymphadenectomy during treatment of endometrial cancers (ECs) and to what extent lymphadenectomy should be performed. In addition, retroperitoneal lymphadenectomy increases the intraoperative and postoperative complications. Sentinel lymph node (SLN) mapping has the lowest costs and highest quality-adjusted survival. SLN is the most cost-effective strategy in the management of low-risk ECs. Women staged with SLN mapping were more likely to receive adjuvant treatment compared with women staged with systemic lymphadenectomy. This review article designed to evaluate the diagnostic accuracy and the methods of SLN detection in ECs.

Prenatal diagnosis of single umbilical artery complicated by intrauterine growth retardation and preterm labor: Case report.

Fetuses with single umbilical artery (SUA) at great risk of intrauterine growth retardation (IUGR), intrauterine fetal death (IUFD) and prematurity. A 24-years-old woman, 28 weeks' gestation, presented to the Ahmadi hospital, Kuwait, with history of preterm premature rupture of fetal membranes (PPROM). After exclusion of the PPROM, the ultrasound scan of the studied woman showed; asymmetrical IUGR with SUA. The diagnosis of SUA confirmed by the color flow Doppler. She delivered spontaneously at 36 weeks+2, and a cut section in the umbilical cord done to confirm the diagnosis of SUA. The congenital and chromosomal abnormalities of the studied neonate excluded after normal pelvi-abdominal, brain ultrasound and normal karyotyping (46, xx); respectively. The prenatal diagnosed SUA in the studied cases associated with IUGR, preterm labor (PTL) and small for gestational age (SGA). SUA can be considered a marker of diagnosable congenital fetal malformation (CFM) and aneuploidy.

Intra-leiomyoma hemorrhage in postmenopausal woman presented with acute abdominal pain.

Intra-leiomyoma hemorrhage in postmenopausal woman is a very rare complication. This case report represents a case report of spontaneous hemorrhage inside the uterine leiomyoma in postmenopausal woman who presented with acute abdomen. A 55-year-old woman, multipara, postmenopausal for 7 years, known case of multiple fibroid uteruses, was presented to the emergency department of Ahmadi Hospital, Kuwait Oil Company, with acute abdominal pain and vomiting, without any reported trauma and/or associated vaginal bleeding. The studied woman was generally stable regarding her vital signs, her hemoglobin dropped from 12 to 10.2 g/dl. Abdominal examination revealed; palpable pelvi-abdominal mass firms in consistency with tenderness and guarding which provisionally support the diagnosis of degenerated fibroids or intra-leiomyoma hemorrhage. The diagnosis was confirmed by basic pelvi-abdominal ultrasound, followed by correction of the patient's general condition and total abdominal hysterectomy with bilateral salpingo-oophrectomy (TAHBSO). Bisected largest cystic fibroid showed brownish serous fluid inside with organized clotted hematoma which confirmed the diagnosis of intra-leiomyoma hemorrhage. Postoperatively, the studied woman received an unit of packed red blood cells for correction of the postoperative anemia and discharged from the hospital in good general condition for postoperative follow-up in the outpatients' department on iron tablets. This case report represents a rare complication of intra-leiomyoma hemorrhage in postmenopausal, diagnosed by the basic clinical and ultrasound findings. The case was managed by TAHBSO after correction of the general condition because of the increased risk of the sarcomatous changes of the uterine fibroid in postmenopausal women.

Heme-bound iron in treatment of pregnancy-associated iron deficiency anemia.

BACKGROUND: The iron requirements increase during the second and third trimesters of pregnancy. Maternal anemia is a leading cause of adverse perinatal outcome. OBJECTIVES: This study was designed to evaluate the efficacy of the heme-bound iron in treatment of pregnancy-associated iron deficiency anemia (IDA). MATERIALS AND METHODS: In all, 122 women with IDA during pregnancy and hemoglobin ≤10 g/dL were studied. The studied women were treated with heme-bound iron tablets for ≥3 months. Pretreatment hemoglobin, ferritin, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH) were compared with the posttreatment values to detect the efficacy of heme-bound iron (Optifer®) in treatment of IDA during pregnancy. RESULTS: The mean pretreatment hemoglobin significantly increased from 8.4 ± 2.7 to 11.2 ± 2.1 g/dL and the mean pretreatment ferritin level significantly increased from 22.6 ± 5.6 to 112.8 ± 4.8 µg/L (P < 0.003 and 0.04; respectively) 3 months after heme-bound iron treatment. In addition, the mean pretreatment red blood cells' MCV and MCH significantly increased from 74.2 ± 4.8 fL and 24.2 ± 7.8 pg, respectively, to 92.0 ± 4.1 fL and 32.6 ± 6.2 pg) (P = 0.04 and 0.007, respectively) 3 months after heme-bound iron treatment. CONCLUSION: Heme-bound iron (Optifer®) is an effective oral iron preparation to treat IDA during pregnancy and to replace the depleted iron store.