Early Diagnosis of Acute Appendicitis in the Second Trimester of Pregnancy Based on Non-typical Clinical Findings: Report of a Rare Case and a Mini-Review of the Literature.

Acute appendicitis is the most common non-obstetric reason for exploratory laparotomy during pregnancy. This case report involves a primigravida patient who presented to the emergency department of the General Hospital of Trikala at 15 weeks of gestation due to diffuse abdominal pain, primarily in the epigastric region. She also reported watery bowel movements. The ongoing atypical clinical symptoms, along with elevated inflammatory markers, strongly indicated a diagnosis of acute appendicitis. An immediate exploratory laparotomy was performed, during which acute localized inflammation of the appendix was found, leading to an appendectomy. Histological examination confirmed the diagnosis of acute appendicitis. The patient reported pain relief immediately after the surgery. On the fourth postoperative day, she was discharged without any signs of a threatened second-trimester miscarriage. At 39 gestational weeks, she delivered by elective cesarean section due to breech presentation. This paper discusses the case and highlights the significant challenges in the early diagnosis and management of acute appendicitis during pregnancy, emphasizing the importance of preventing potentially life-threatening complications for both the mother and the fetus.

Prenatal Diagnosis of Vasa Previa in the Second Trimester of Pregnancy Based on Non-typical Ultrasound Findings: A Case Report and Mini-Review of the Literature.

Vasa previa is a rare disorder of the placenta. The absence of a prenatal diagnosis is associated with increased perinatal morbidity and mortality. In our patient, ultrasound findings, although atypical, successfully established the prenatal diagnosis of vasa previa in the second trimester of pregnancy. Despite the fact that the placenta was not low-lying, that it was not possible to visualize the site of umbilical cord insertion into the placental tissue, and that vasa previa was not directly visualized, the presence of blood flow near and around the internal cervical os, as seen on transvaginal Doppler ultrasound in the second and third trimesters of pregnancy, raised serious suspicion of their presence. With the completion of the 36th gestational week, it was decided to proceed with a scheduled cesarean section. One week earlier, a course of corticosteroids was administered. The cesarean section was performed without complications. After placental delivery, the presence of velamentous umbilical cord insertion was noted, with umbilical vessels coursing unprotected by the placental tissue or umbilical cord within the fetal membranes. The puerperant and the newborn were discharged from the obstetrics clinic of the General Hospital of Trikala in excellent condition. This paper highlights the importance of transvaginal color Doppler ultrasound in the prenatal diagnosis of vasa previa, which, while posing little risk to the mother, can often be fatal to the fetus.

Abdominal Wall Endometriosis: Early Diagnosis of a Rare Iatrogenic Complication Following Cesarean Section.

Abdominal wall endometriosis is a rare form of extrapelvic endometriosis, frequently diagnosed with delay in most cases. It is typically iatrogenic and primarily associated with procedures such as cesarean sections or other gynecological surgeries. In our patient, endometriosis at the laparotomy scar was diagnosed relatively early, approximately two months after the onset of symptoms, which manifested 10 months after the last cesarean section. The patient, who had an obstetric history of three cesarean sections, presented at the Gynecology outpatient clinic of the General Hospital of Trikala, complaining of pain associated with menstruation located in the lower abdomen, near the surgical scar. Based on clinical and imaging findings, abdominal wall endometriosis was suspected, leading to a decision for wide excision of the endometriotic lesion. Histological examination of the surgical specimen confirmed the diagnosis. The postoperative course was uneventful, and three months after the surgery, the patient reported complete resolution of symptoms. This case report emphasizes the importance of integrating advanced diagnostic methods alongside classic clinical findings for the accurate diagnosis of abdominal wall endometriosis. It also highlights the contribution of surgical treatment through wide excision of the endometriotic lesion, in facilitating early diagnosis, achieving cure, and minimizing the risk of disease recurrence in the future.

Fibroepithelial Polyp of the Vagina With Torsion: A Difficult Diagnosis Based on Clinical and Morphological Findings of the Vaginal Lesion.

Vaginal fibroepithelial polyps are rare benign tumors of the mucosa of the anterior vaginal wall. In extremely rare cases, they may originate from the posterior vaginal wall or be complicated by torsion. Our case concerns a 63-year-old patient who presented to the gynecology outpatient clinic of the General Hospital of Trikala with minor vaginal bleeding. On vaginal examination, a large pedunculated painless hemorrhagic polypoid mass was noticed, originating from the posterior vaginal wall. A torsion of the pedunculated vaginal tumor was suspected, leading to its surgical excision with clear resection margins. Due to extensive tissue necrosis, accurate histological identification of the vaginal neoplasm was not possible. Histological examination excluded vaginal malignancy. Based predominantly on the clinical and morphological features of the vaginal lesion, a diagnosis of vaginal fibroepithelial polyp with torsion was made, acknowledging its limitations. The patient was discharged from the clinic the same afternoon following the surgery. Three months later, no recurrence of the lesion in the vaginal wall was noted. Following the case presentation, this paper provides a brief literature review of this rare entity, focusing on the diagnostic and therapeutic approaches.

Interstitial Ectopic Pregnancy Associated With Painless and Severe Vaginal Bleeding: A Rare, Atypical Clinical Presentation.

Interstitial ectopic pregnancy is rare (2%-4% of ectopic pregnancies). The atypical clinical presentation of interstitial ectopic pregnancy associated with massive vaginal bleeding is extremely rare and makes early preoperative diagnosis even more difficult. The presentation of our case concerns the early diagnosis and surgical treatment of a patient with an interstitial ectopic pregnancy without rupture, which presented atypically with painless, severe vaginal bleeding. A 27-year-old fourth-term pregnant woman presented with massive painless vaginal bleeding. Secondary amenorrhea was calculated at eight weeks and four days. Transvaginal ultrasound and transvaginal Doppler ultrasound combined with the quantification of beta-chorionic gonadotropin hormone raised the suspicion of interstitial ectopic pregnancy. Intraoperatively, the presence of a large swelling of the right horn of the uterus was established, and a wedge resection was performed with the removal of the corresponding fallopian tube. Three weeks after surgery, the serum beta-chorionic gonadotropin hormone value was zero. In this paper, the rarity of interstitial ectopic pregnancy, the difficulties related to early and correct preoperative diagnosis, and the selection of the appropriate available therapeutic procedures are emphasized, the correct application of which can significantly contribute to reducing the morbidity and mortality of these patients.

Large Extracervical Posterior Pedunculated Leiomyoma of the Uterus With the Only Symptom of Chronic Low Back Pain From Radiculopathy: A Case Report.

Large extra cervical-type posterior subserosal leiomyomas originating from the cervix are extremely rare. Our case concerns the surgical treatment of a large posterior pedunculated subserosal extracervical leiomyoma of the uterus with extension to the retroperitoneal space, which was associated with chronic low back pain. A 45-year-old patient, without menstrual disorders and with a medical history of chronic low back pain with sciatica, was referred for gynecological evaluation. The gynecological examination revealed the presence of a large pelvic mass, which occupied the pouch of Douglas. Preoperative imaging confirmed the presence of a solid pelvic mass, but its origin could not be clarified. Neither transvaginal ultrasound nor MRI could establish the diagnosis of extracervical leiomyoma of the uterus. Based on the clinical and imaging findings, surgical management of the patient was decided with laparotomy. Intraoperatively, a large extracervical pedunculated leiomyoma was found, which originated from the posterior wall of the cervix and extended into the retroperitoneal space. An abdominal total hysterectomy and bilateral salpingo-oophorectomy were performed. The procedure had significant surgical difficulties. The postoperative course was uneventful. Three months after surgery, the patient reported relief of symptoms. This paper highlights a brief review of cervical leiomyomas, highlighting the important difficulties regarding the preoperative diagnosis and surgical management of these patients.

Adnexal Torsion of a Mature Cystic Ovarian Teratoma With Hemorrhagic Infarction Misdiagnosed As Pelvic Inflammatory Disease in a Perimenopausal Patient: A Case Report.

Mature cystic teratomas are common benign ovarian tumors. They usually occur in young women, less than 40 years old. Our case report concerns a patient of perimenopausal age who came to the hospital complaining about mild abdominal pain, fever below 37.8°C, and diarrhea. The patient had an intrauterine contraceptive device inserted. Based on the clinical findings and imaging, a possible diagnosis of pelvic inflammatory disease was set, and intravenous administration of broad-spectrum antibiotics started immediately. The decision for performing laparotomy was taken after the fact that the clinical condition and blood tests of the patient had shown no improvement. Intraoperatively, the presence of a large twisted ovarian mass with signs of total necrosis due to adnexal torsion was detected. A histological examination of the surgical specimen confirmed the diagnosis of mature cystic teratoma in the right ovary. The postoperative course was uneventful. The presentation of the case follows a brief literature review of this rare medical condition regarding the diagnostic and therapeutic approach of these patients.

Pueperal Paratubal Cyst Torsion and Secondary Fallopian Tube Torsion Without Ovarian Involvement: A Case Report.

Paratubal cyst torsion accompanied by secondary isolated fallopian tube torsion without involvement of the ipsilateral ovary is rare. A similar case occurring in the postpartum period has not been reported to date in the English literature. Our case report concerns a pregnant multiparous woman in the 40th gestational week, without regular antenatal care attendance, who was urgently admitted to the maternity ward with pushing labour pains and gave birth with vaginal delivery. A few hours later, puerperant complained of worsening severe lower abdominal pain, accompanied by nausea, dizziness and vomiting, unresponsive to analgesic medication. Based on the clinical and ultrasound findings, the diagnosis of an ovarian cyst torsion was established, and it was decided to treat the patient with surgery and in particular with laparotomy. Intraoperatively, in the left parametrium, the presence of an ovoid mass with a brownish-red hue and a smooth outer surface was detected, along which the ipsilateral fallopian tube ran, without the involvement of the ovary. Histological examination of the surgical specimen confirmed the diagnosis of isolated fallopian tubal torsion with paratubal cyst. The postoperative course was uneventful. In this paper, based on modern data, a brief literature review of this rare nosological entity is attempted, regarding the diagnostic and therapeutic approach, the immediate application of which can ensure the best prognosis.

Surgical Treatment of a Rare Case of Ovarian Fibroma Associated With Elevated CA125 Levels in a Patient of Reproductive Age: A Case Report.

Small ovarian fibromas (< 10cm) associated with elevated serum CA125 levels are rarely encountered, particularly in women of reproductive age. We report a rare case diagnosed in a 35-year-old patient after adnexectomy for a solid ovarian mass of approximately 5cm in maximum diameter, accompanied by elevated serum CA125 levels. In preoperative evaluation, no signs of inflammation from the genital tract were found, and no medical history of endometriosis, uterine leiomyomas, or non-gynecological cancer was reported. Intraoperative frozen section biopsy of surgical specimen obtained from the ovarian tumor had negative evaluation for malignancy. Histological examination of the surgical specimen confirmed the diagnosis of ovarian fibroma. The postoperative course was uneventful. Two months after surgery, the blood serum CA125 levels were within normal ranges. The patient is assessed at regular intervals in the gynecology outpatient clinic. In this paper, based on the data of the modern literature, a brief review of this rare nosological entity is made.

Large Cervical Leiomyoma of the Uterus: A Rare Cause of Chronic Pelvic Pain Associated With Obstructive Uropathy and Renal Dysfunction: A Case Report.

Large cervical leiomyomas (≥10cm) are extremely rare. Our case report concerns the surgical treatment of a patient with a large cervical leiomyoma associated with chronic pelvic pain, bilateral hydroureteronephrosis and significant impairment of renal function. A 47-year-old patient of reproductive age with a normal menstrual cycle and a medical history of chronic pelvic pain presented to the gynecology clinic for examination. Clinically, the presence of a large pelvic mass was found, the upper margins of which were palpable at the level of the umbilicus. A preoperative assessment revealed bilateral hydroureteronephrosis due to obstructive uropathy and renal dysfunction. Hydroureteronephrosis, as a consequence of the large pelvic mass, probably originating from the cervix of the uterus, was evaluated as the main cause of renal dysfunction. Tumor markers were negative. The imaging studies confirmed the clinical diagnosis of uterine leiomyoma, and the surgical treatment of the patient with laparotomy was decided. Intraoperatively, the presence of a large uterine cervical fibroid was detected, and a total abdominal hysterectomy and bilateral adnexectomy were performed. Operating was difficult, with significant surgical difficulties. The postoperative course was uneventful, without immediate complications. The patient's symptom relief began gradually, immediately after surgery. Three months after surgery, the patient reported complete relief of her pelvic pain. A re-examination of the urinary tract revealed complete recovery of renal morphology and function. In the paper, after the presentation of the case, a brief review of cervical leiomyomas is attempted based on the literature, mainly regarding the diagnostic and therapeutic approach.

Surgical Treatment of a Large Post-cesarean Hematoma in the Retzius Space Accompanied by a Blood Coagulation Disorder: A Rare Case Report.

Hematoma in the Retzius space after a cesarean section is a rare complication. The Retzius space, also referred to as the prevesical or retropubic space, represents an extraperitoneal artificial cavity situated between the pubic symphysis and the bladder. In instances where conservative treatment involving vigilant monitoring along with analgesics and antibiotics or ultrasound-guided percutaneous puncture proves unsuccessful, re-operation becomes imperative. Our case report concerns a second-parity pregnant patient who underwent a cesarean section in the 39th gestational week. A decrease in hemoglobin level on the third postoperative day, combined with the onset of febrile infection, an increase in inflammatory markers, and the manifestation of lower abdominal pain, prompted a thorough investigation of the puerperant. Imaging revealed the existence of a hematoma in the Retzius space associated with a mild blood coagulation disorder. Subsequently, the unsuccessful outcome of the ultrasound-guided percutaneous puncture of the hematoma, combined with the persistence of clinico-laboratory findings, led to the decision to perform a re-laparotomy on the 10th postoperative day after the cesarean section. During the surgery, a large hematoma was identified in the Retzius space, extending below the rectus abdominis muscles. The procedure involved surgical drainage of the hematoma, meticulous hemostasis, and the placement of negative pressure drainage in the Retzius space. The patient was discharged from the clinic on the fifth postoperative day after re-operation. Ten days later, both blood tests and ultrasounds were without abnormal findings. In this paper, following the case presentation, a brief review is provided regarding the diagnostic and therapeutic approach of patients with hematoma in the Retzius space after cesarean section.

Awareness Regarding Human Papilloma Virus Among Health Professionals and Will to Accept Vaccination: A Systematic Review.

Human Papilloma Virus (HPV) infection is the most common sexually transmitted disease and the leading cause of cervical cancer. The undeniable causal link between HPV and cervical cancer led to the creation of HPV prophylactic vaccines. Health professionals are key in counseling parents about their children's immunization, as they are considered valid and reliable sources of information. The systematic review aimed to determine doctors' and nurses' knowledge of HPV, their awareness of the vaccine, and their willingness to accept vaccination. Systematic studies were conducted from 2015 to January 2022 in Medline/PubMed and Google Scholar online databases. The systematic review included 10 good-quality cross-sectional studies and a total of 6700 participants who were administered self-administered questionnaires or personal interviews. From the analysis of most of the studies, it is demonstrated that health professionals have a satisfactory level of knowledge about HPV infection and its effects on human health, even if their knowledge gap in essential details regarding the virus and HPV vaccination is apparent. It was found that various factors regarding health professionals, such as their specialty, gender, working environment, weekly working hours, and the interval since their last HPV training, contribute to forming their knowledge level about HPV and vaccination. In addition, most studies show that most healthcare professionals knew about the existence of HPV vaccines but did not know many details about how their work and their potential benefits. In conclusion, the provision of counseling by health professionals is currently estimated to be the strongest predictor of target group compliance with the HPV vaccine. Consequently, it is essentially considered to investigate the HPV-related knowledge level among health workers and to intensively reeducate them regarding the HPV infection risks and the necessity of HPV vaccination to improve their awareness and strengthen their attitude in favor of vaccination against cervical cancer.

Rupture of Ectopic Ovarian Pregnancy Accompanied by Massive Intra-abdominal Bleeding and Disorder of the Coagulation Mechanism: A Rare and Life-Threatening Obstetric Complication.

The rupture of ectopic ovarian pregnancy accompanied by massive intra-abdominal bleeding is a rare obstetric complication, occurs predominantly in the first trimester of pregnancy, and can be dangerous and life-threatening for the pregnant woman. Our case describes a 37yr old woman with a history of 4 lower segment Cesarian sections (LSCS) (Caesarean sections) and multiple surgical abortions, presenting at the ER with acute abdomen symptoms. The patient's hemodynamic status was unstable. The positive urine pregnancy test combined with the clinical and ultrasound findings established the diagnosis of the ruptured ectopic pregnancy, and immediate surgical treatment was decided. During surgery, a large amount of blood was found in the peritoneal cavity, resulting from a rupture of the right ovary and accompanied by hemorrhagic infiltration of adjacent tissues, without participation in the damage of the ipsilateral fallopian tube. It was deemed necessary to remove the ipsilateral adnexa and whole blood transfusion. The patient was discharged from our department on the fourth postoperative day. The price of beta-chorionic gonadotropic hormone was on a downward trend. Three weeks later, the level of beta-chorionic gonadotropic hormone was zero. In the present paper, a brief review is attempted regarding the diagnostic and therapeutic approach for patients with ruptured ectopic ovarian pregnancy after describing the case.

Primary Fallopian Tube Carcinoma: An Extremely Rare Gynecological Cancer Misdiagnosed Intraoperatively as Benign Ovarian Neoplasm: A Case Report.

Primary fallopian tube carcinoma is very rare. Diagnosis is challenging. The description of our case concerns an asymptomatic 71-year-old patient who came for a routine gynecological examination. Imaging of the pelvis revealed the presence of a two-chambered cystic formation in the anatomical position of the right ovary. It was decided to investigate the disease by laparotomy. Examination of the frozen section from the site of the cystic lesion was negative for malignancy. An abdominal total hysterectomy was performed with bilateral salpingo-oophorectomy. Serous carcinoma of the fallopian tube was diagnosed postoperatively by histological examination of the surgical preparation. Immediately after surgery, the patient's health was good.The patient was referred to an oncology center and was monitored. Chemotherapy based on platinum and taxane was recommended. Six months after the operation the patient is in good health. The possibility of a second surgery to treat fallopian tube cancer with pelvic lymph node dissectionis under discussion and is expected to be decided by oncologists and gynecologists-oncologists. In this article, after describing the case report, a brief review of this rare entity disease's diagnostic and therapeutic approach is attempted.