Conservative laparoscopic management of a large cornual ectopic pregnancy

Cornual pregnancy traditionally has been treated with laparotomy and either cornual resection or hysterectomy. Recently, more conservative operations have been developed, and operative laparoscopy has provided yet another management option. This report describes the conservative management of a large cornual ectopic pregnancy and reviews the techniques and outcomes of conservative repair that have been described in the literature.     

Successful management of ruptured choledochal cyst by primary cyst excision and biliary reconstruction

One to two percent of patients who have choledochal cysts present with cyst rupture and bile peritonitis. Reported cases have been managed with external drainage of the cyst followed by a second procedure to excise the cyst and reconstruct the biliary tract. The authors report two cases of ruptured choledochal cyst treated with primary cyst excision and biliary drainage. The satisfactory outcome of these patients suggests that this is the preferred management.     

Successful management of primary left ventricular aneurysm (of the apex) in a child

A technique has been worked out for determining amino alkyl phosphonic acids in ruminal fluid by using methods of hydrolysis, partition of the phosphonic acid on a cation exchange column and ashing of the eluate. After evaporation to total dryness the phosphonic acids were determined as phosphates. The amounts of acid found in the ruminal fluid of goats varied between 0.4 and 1.1 muMol/ml. In view of the fact that these acids are microbial compounds it will appear that any change in the amount of compounds produced in the rumen would indicate changes in the concentration of the microbial mass in the rumen.     

Successful pregnancy outcome following Tompkins metroplasty done early in pregnancy

A hysterosalpingogram revealed a septate uterus in a 29 year old nulliparous woman with a history of recurrent pregnancy loss. The patient underwent Tompkins metroplasty in the proliferative phase of the menstrual cycle. One month after the operation she presented with a delay in her menses and a positive pregnancy test. Ultrasound revealed a viable fetus commensurate with 10 weeks gestation, making the gestation period 5 weeks at the time of surgery. After reviewing the patient's menstrual history it was found that the period the patient had before surgery was on time but with unusually minimal bleeding. A repeat ultrasound scan for anomaly done 7 weeks later was commensurate with 17 weeks gestation. The patient carried her pregnancy for the first time until approximately 37 weeks when she delivered by Caesarean section a healthy female baby weighing 3700 g.     

Medical management should be routinely used as primary therapy for ectopic pregnancy

It does not appear that methotrexate can or should be used to totally replace laparoscopic salpingostomy. However, given its success rate in selected patients, its cost-effectiveness, and its low incidence of side effects, methotrexate therapy certainly can be used as an alternative therapy. The next step in developing this treatment option will be to conduct a randomized clinical trial comparing laparoscopic salpingostomy with intramuscular methotrexate. This type of study will answer questions regarding the patient's health related quality of life and economic impact of the two treatment modalities. For now, it seems prudent to offer methotrexate to those patients with an unruptured ectopic gestational mass 3.5 cm or less in greatest dimension.     

Massive ascites due to abdominal pregnancy

We describe a case of an abdominal pregnancy which presented in the first trimester with rapid accumulation of blood stained ascites. The ascites resolved completely following surgical removal of a gestational sac from the peritoneal cavity. The pathophysiology of ascites in this case may be similar to that in cases of ascites in other non-malignant gynaecological conditions.     

Successful pregnancy in a separated conjoined twin

A case of successful pregnancy in a separated conjoined twin is described. The patient underwent cesarean delivery because of the reconstructed pelvis and extensive perineal reconstruction, which resulted in dense fibrosis. Surgical records and communication with the patient's pediatric surgeons were helpful in planning for delivery.     

Successful management of secondary aortoesophageal fistula

Aortoesophageal fistula is a rare complication after thoracic aortic aneurysm repair. Six previously reported cases of aortoesophageal fistula management have been uniformly fatal. We present our successful management and review the literature of this topic.     

Arthrogryposis multiplex congenita in an abdominal pregnancy

Dextropropoxyphene hydrochloride increases significantly oxygen uptake in whole rat brain homogenates at concentrations of 10(-4), 10(-5), 10(-6) M when using sucrose 0.25 M pH 7.4 as incubation medium. If substrate and cofactors are added to the sucrose, this drug decreases oxygen uptake at 10(-3) M concentration in brain and liver rat homogenates, and it also decreases significantly the P:O quotient of mitochondria in both organs by uncoupling the oxidative phosphorylation.     

Cholecystocolic fistula at laparoscopic cholecystectomy: primary closure and laparoscopic caecostomy

This report suggests a strategy for managing unsuspected cholecystocolic fistula discovered during laparoscopic cholecystectomy by means of tube caecostomy.     

Successful pregnancy outcome in uterus didelphys with leiomyoma uteri

Müllerian anomalies are in different degrees complicated by poor fetal outcome. Our young patient had in addition to uterus didelphys a leiomyoma of the nonpregnant part of the double uterus. Though her pregnancy was complicated, it was conserved to 37 weeks, when the baby was delivered by cesarean section. The right uterine body with a leiomyoma weighing 1500 grams was removed at the same time.     

Conservative management of extra-uterine pregnancy

Expectant management was studied in 35 patients representing 4.9% of all ectopic pregnancies during an 8 year period. Laparoscopy was performed in a first period to define the inclusion criteria: hematosalpinx < or = 2 cm and hemoperitoneum < or = 50 ml. In a second period, inclusion criteria used a predictive pretherapeutic score < or = 11 with a sonographic visualization of the ectopic pregnancy. This score involved six criteria graded on a scale from 1 to 3: gestational age, hCG and P level, existence of abdominal pain, size of hemoperitoneum and diameter of hematosalpinx assessed sonographically. The patients were on out-patients basis. Success rate was 85.7% (30/35 patients). When the pretherapeutic score was < or = 11 and the initial hCG level < 1,000 mUl/ml the success rate increased to 96%. Thirteen patients (87%) had patent tubes evaluated by hysterosalpingography on the side of the ectopic pregnancy. Twelve patients delivered one miscarriage occurred and none ectopic pregnancy was observed. Expectant management is a useful form of treatment for ectopic pregnancy in selected cases.     

Active management of prolonged pregnancy

OBJECTIVES: We assessed perinatal morbidity and mortality of prolonged pregnancies (> or = 294 days) compared with those of term gestations. We also evaluated the impact of induction of labor compared with spontaneous onset of labor. STUDY DESIGN: This observational study included consecutive cases treated at Chicago Lying-In Hospital from July 1980 to December 1984. Complications, presence of meconium, indications for cesarean section, mode of delivery, perinatal morbidity (and mortality), meconium aspiration, and duration of labor were compared with those in the total hospital population, in infants weighing > or = 2500 gm, and within prolonged gestation groups; spontaneous onset and induced ("active management") labors were also compared. The chi 2 analysis was used. RESULTS: Of 12,930 deliveries there were 707 prolonged gestations (5.5%) and 10,698 with infants > or = 2500 gm. Among the prolonged gestations 67% were in multiparous women and 33% in primiparous women. Labor started spontaneously in 62%, and 38% underwent induction; the overall cesarean section rate was 17% with similar indications in both spontaneous onset and induction groups. Meconium was present in 34%; it was present in 23% of inductions, which is fewer (p < 0.01) than among those with spontaneous onset of labor (40%). Also there were fewer depressed neonates at 5 minutes (p = 0.03) among inductions. Meconium aspiration was seen in 24, with nine deaths. The perinatal mortality was 14 per 1000 (corrected 12.7/1000), significantly more than in the general population. Among those with spontaneous onset of labor it was 20.5 per 1000; there were no deaths among inductions. Postpartum maternal morbidity was 16% among cesarean sections and 4% among vaginal deliveries. CONCLUSIONS: Prolonged gestation has a high perinatal morbidity and mortality rate. All perinatal deaths were observed among patients whose labor started spontaneously. "Active management" (induction at 42 weeks) did increase the primary cesarean section rate compared with that of the general obstetric population; it did not do so among prolonged gestations and prevented perinatal deaths in this group. From this experience an active approach seems justified.     

Successful pregnancy after spontaneous remission of familial pulmonary alveolar proteinosis

In this report we describe a case of a successful pregnancy in a 19-year-old patient suffering from the familial form of pulmonary alveolar proteinosis, a very rare pulmonary disorder. The pregnancy course was complicated by preterm labour. The outcome and management are discussed.     

Prophylactic vasopressin during laparoscopic salpingotomy for ectopic pregnancy

Monoamine oxidase (MAO) released from the rat liver into plasma and the activity levels of lipid peroxide (LPO) and superoxide dismutase (SOD) in liver tissue were investigated after pretreatment of rats with the perilobular hepatotoxin allyl formate (AF). When 3H-pargyline was given to AF-pretreated rats, the levels of 3H-pargyline labelled MAO in rat plasma were increased to 38% (p < 0.01 vs control), but the radioactivity was decreased to 35% (p < 0.05 vs control). The molecular weight of MAO subunits in plasma was similar to that of MAO subunits in liver (about 60,000) as determined by SDS electrophoresis. Liver tissue LPO levels in these rats were increased, whereas SOD activity was decreased. These results suggest that MAO in liver mitochondria was released into plasma as a consequence of membrane disorder.     

Successful management of heart rupture from blunt trauma

Seven patients with cardiac rupture from blunt trauma were encountered at the University Hospital, University of Alabama School of Medicine, in a 15-year period. Five of seven patients survived, including three with left atrial injuries and one each with right ventricular and left ventricular injuries. Useful diagnostic features included systolic hypotension, distended neck veins, and elevated central venous pressures. Associated injuries averaged four per patient. Successful management demands a high index of suspicion of cardiac injury, prompt diagnosis, and immediate median sternotomy. After repair of the heart the incision should usually be extended to allow exploratory laparotomy.     

Role of laparoscopic ultrasound in cancer management

Clinical practice guidelines have enormous potential to improve the quality of and accountability in health care. Making the most of this potential should become easier as guideline developers integrate guidelines within information systems and electronic medical records. A major barrier to such integration is the lack of computing infrastructure in many clinical settings. To successfully implement guidelines in information systems, developers must create more specific recommendations than those that have been required for traditional guidelines. Using reusable software components to create guidelines can make the development of protocols faster and less expensive. In addition, using decision models to produce guidelines enables developers to structure guideline problems systematically, to prioritize information acquisition, to develop site-specific guidelines, and to evaluate the cost-effectiveness of the explicit incorporation of patient preferences into guideline recommendations. Ongoing research provides a foundation for the use of guideline development tools that can help developers tailor guidelines appropriately to their practice settings. This article explores how medical informatics can help clinicians find, use, and create practice guidelines.