Heterotopic pregnancy presenting with acute left chest pain.

Heterotopic pregnancy is the simultaneous existence of intrauterine and ectopic gestations. Heterotopic pregnancy is an extremely rare entity in natural cycle; however, it is increasing due to widespread use of assisted reproductive techniques. Early diagnosis and intervention are crucial in avoiding short- and long-term morbidity and mortality. Unfortunately, early diagnosis is often difficult due to the presence of intrauterine pregnancy that impedes the diagnosis and early treatment for ectopic component. Clinical symptoms are not generally helpful in diagnosis, and signs of the ectopic pregnancy usually predominate. Patients will most likely present with abdominal pain, adnexial mass, enlarged uterus, peritoneal irritation signs, and a positive pregnancy test. We present a case, admitted to the emergency department, with atypical symptoms including acute left chest pain radiating to left shoulder, at 5 weeks' gestation.

Effects of menstrual cycle on postoperative analgesic requirements, agitation, incidence of nausea and vomiting after gynecological laparoscopy.

BACKGROUND: Several studies have suggested that the menstrual cycle has an impact on postoperative nausea and vomiting (PONV). No previous study has evaluated the effect of the menstrual cycle on the incidence of postoperative agitation and analgesic/antiemetic requirements. METHODS: On the basis of the phase of the menstrual cycle [pre+/-menstrual (Pd 25-6), early follicular phase (Pd 8-12), ovulatory phase (Pd 13-15), and luteal phase (Pd 20-24)], 67 patients enrolled in this blinded, prospective study. Anesthesia was standardized. Fentanyl was given to the patients who had severe pain in the recovery room. The patients who had agitation were given midazolam. When pain intensity was >5 on the Visual Analog Scale, metamizol was administered in the Gynecology Department. A blinded anesthesiologist recorded episodes of PONV in the recovery room, and 2 and 24 h postoperatively. RESULTS: The opioid requirement and the frequency of agitation were similar in each group. Metamizol consumption was highest in the luteal phase (p < 0.05). The follicular and luteal phases were predictors for vomiting at recovery (p < 0.05 and p < 0.001, respectively). At the postoperative 2nd hour, nausea was higher in the follicular phase than in the other phases (p < 0.05) and the luteal phase was a predictor for retching (p < 0.001). At the postoperative 24th hour, nausea was the common symptom in the luteal phase (p < 0.05). The need for ondansetron was highest in the luteal phase (p < 0.01). CONCLUSIONS: In conclusion, we suggest that the scheduling of all surgical procedures according to the menstrual phase may serve to reduce the incidence of PONV and metamizol/ondansetron consumption and hospital costs.