Daniel C. Darrow

OBJECTIVE: To determine whether magnetic resonance imaging (MRI) in pregnancy would help define a benign pelvic mass, thereby avoiding laparotomy. METHODS: During a 2-3-year period, five pregnant women with adnexal masses suspected to be leiomyomas underwent MRI. RESULTS: Four patients had evidence of leiomyoma and one had a benign cystic teratoma. All avoided laparotomy because of the almost certain radiologic findings of a benign process. In two women, there was an important effect on the pregnancy; one had fetal growth retardation and the other an outlet obstruction precluding vaginal delivery. Four of the patients underwent cesarean delivery. CONCLUSIONS: Magnetic resonance imaging can be used in the differential diagnosis of an adnexal mass in pregnancy. This will enable some pregnant patients to avoid laparotomy and its concomitant risks.     

Isolated ovarian polyarteritis nodosa

Polyarteritis nodosa is a rare disorder and a form of systemic vasculitis. A 48 year-old female was admitted to the hospital because menorrhagia and pelvic pain in February 1993. The patient underwent exploratory laparotomy resulting in a total hysterectomy and bilateral salpingo-oophorectomy for myoma of uterus and a right adnexal cystic mass. Histopathologic examination revealed left ovarian periarteritis nodosa. Further investigation and 9 months follow-up failed to show any systemic involvement. To our knowledge the isolated ovarian polyarteritis nodosa is the first case in the literature.     

Platelet transfusion practice: time for renewed consensus

BACKGROUND: Bilateral tubal pregnancies are rare and are usually confirmed simultaneously during the same operation. We report a case in which the right salpingectomy was performed seven weeks before the left salpingectomy. When the right salpingectomy was done, the left uterine tube appeared entirely normal. CASE: A 38-year-old woman underwent laparoscopic surgery for suspected right tubal pregnancy. A right tubal pregnancy was found to have partially aborted into the peritoneal cavity. The left uterine tube was carefully inspected and appeared normal. Histopathology of the right tube showed products of conception and chorionic tissue. Seven weeks after surgery, the woman presented in hemorrhagic shock necessitating emergency laparotomy and left salpingectomy. Histopathology of the left tube confirmed the presence of chronic tissue. The patient did not have coitus between the two salpingectomies. CONCLUSION: The explanation of the presentation is uncertain. However, this case underscores the importance of careful follow-up of patients after laparoscopic surgery for ectopic pregnancies.     

Hemangioma of the ovary. A case report

BACKGROUND: Ovarian hemangioma is extremely rare. CASE: We report a case of a 32-year-old woman who complained of pelvic pain due to a large right adnexal mass. On color Doppler sonography the mass showed very rich and complex vascularity, with prominent blood flow. A 10 x 8-cm hemangioma of the right ovary was resected. CONCLUSION: Hemangiomas should be considered when a richly vascularized tumor with prominent blood flow is detected on color Doppler sonography or magnetic resonance imaging.     

The role of laparoscopy in the management of pelvic pain in women of reproductive age

OBJECTIVE: To review the diagnostic and therapeutic roles of laparoscopy in women of reproductive age with acute and chronic pelvic pain. DATA IDENTIFICATION: Studies relating to the use of laparoscopy in women with acute and chronic pelvic pain were identified through the literature and MEDLINE searches. CONCLUSION(S): Laparoscopy has an important place in the management of conditions that cause acute pelvic pain in women of reproductive age, including ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess, and adnexal torsion. The procedure frequently facilitates the diagnosis and provides the necessary access for surgical treatment. Prompt diagnosis and effective management prevent complications and help preserve fertility. The role of laparoscopy in women with chronic pelvic pain is more controversial and limited, but abnormal laparoscopic findings are detected in approximately 60% of those who have undergone a multidisciplinary investigation and received a tentative clinical diagnosis. The access provided by laparoscopy permits the effective surgical treatment of many of the conditions encountered, including endometriosis, pelvic adhesions, ovarian lesions, and symptomatic uterine retroversion.     

Efficacy and safety of permanent cardiac DDD pacing with contemporaneous double spinal cord stimulation

A case of simultaneous bilateral tubal pregnancy resulting from in-vitro fertilization and embryo transfer is presented. Repeated transvaginal ultrasound examinations confirmed an intrauterine sac but no fetus. A diagnosis of early missed abortion was incorrectly made and a curettage was performed. The pathological examination showed the presence of decidua and Arias-Stella phenomenon but no chorionic villi. Diagnostic laparoscopy and laparotomy performed 40 days after embryo transfer (eighth week of gestation), revealed bilateral tubal pregnancy. Bilateral salpingectomy was performed.     

The spiritual and psychological explanations for loss experience

OBJECTIVE: To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal mass and non-obstetric surgery, incorporating the results of a series of 9 cases of laparoscopy during pregnancy at our centers. MATERIALS AND METHODS: A Medline search was performed to review the literature, and the reference lists provided by those articles were further explored for citations regarding laparoscopic adnexal surgery, appendectomy, and cholecystectomy. Our series of 9 patients consisted of pregnant patients with adnexal mass or acute abdomen who would otherwise have undergone exploratory laparotomy. Follow-up data for these 9 cases were collected by office visits, inquiry to the primary referring physicians, and telephone calls to the patient. RESULTS: The literature search yielded 42 additional cases of operative pelvic laparoscopy and 51 cases of abdominal operative laparoscopy (cholecystectomy and appendectomy). The publications, particularly regarding cholecystectomy, were supportive of the laparoscopic approach during pregnancy. All of the patients in our series had favorable outcomes. CONCLUSIONS: Advanced operative laparoscopy has been successfully performed for certain indications during pregnancy.     

Critical importance of in vivo amoxicillin and cefotaxime concentrations for synergy in treatment of experimental Enterococcus faecalis endocarditis

Although a higher incidence of ectopic pregnancy has been reported after in-vitro fertilization (IVF) and embryo transfer, three ectopic pregnancies in the same woman is very rare. A patient of 32 years underwent IVF-embryo transfer six times within 3 years. Three of four conceptions resulted in ectopic pregnancies. The first involved simultaneous intrauterine and left tubal pregnancy, the second was a right tubal pregnancy, and the third was a right interstitial pregnancy. In IVF-embryo transfer, bilateral salpingectomy does not remove the risk of interstitial or cornual pregnancy.     

Endodermal sinus tumor and embryonal carcinoma of the ovary in a 53-year-old woman

BACKGROUND: Germ cell tumors, the most common ovarian malignancies in females under the age of 21, are rare in older women. We report an unusual case of a mixed embryonal carcinoma and endodermal sinus germ cell tumor in a perimenopausal patient and review the differential diagnosis and management of these malignancies with respect to age. CASE: A 53-year-old woman complaining of irregular menses and pelvic pain was found to have a large pelvic mass and a positive pregnancy test. Subsequent investigation revealed a large left adnexal mass, and an elevated beta-HCG and alpha-AFP. At laparotomy, a mixed germ cell tumor was found. The patient was treated with multiagent chemotherapy and currently is without evidence of disease. CONCLUSION: Although rare, the diagnosis of germ cell tumor should be considered in older women presenting with a large pelvic mass. The treatment and prognosis is similar regardless of age, except that reproductive-sparing surgery is not a priority in the older patient.     

Evaluation of T-lymphocytes in esophageal mucosal biopsies

OBJECTIVE: To modify and improve a protocol for surveillance of patients presenting for routine elective abortion services. METHODS: Six hundred seventy-four women presenting for routine elective first-trimester abortions were studied. All were 84 or fewer days after the last menstrual period, had no history of bleeding, and had positive urine pregnancy tests. Each woman was scanned initially with an empty-bladder transabdominal technique. If no sac was seen, endovaginal ultrasonography was performed. All terminations had modified gross examination of tissue (3x magnification) as well as staining for microscopic analysis. RESULTS: Six hundred twelve patients (90.8%) demonstrated intrauterine gestations on transabdominal ultrasound, 595 of which were 12 or fewer weeks. Suction and sharp curettage and examination of tissue revealed products of conception in all. Seventeen subjects (2.5%) were found to be 13 or more weeks despite bimanual examinations and last menstrual period suggesting 12 or fewer weeks. Sixty-two patients had no sac seen on transabdominal ultrasound, 34 of whom had definitive intrauterine gestations on endovaginal ultrasound. Curettage revealed chorionic villi in all. Two had unruptured definitive ectopic pregnancies seen on endovaginal ultrasound. Twenty-one women with no sac seen on endovaginal ultrasound underwent curettage as the next step in triage; chorionic villi proved an intrauterine gestation in 17. The additional four had decidua only on pathology. Rising hCG levels in two of these four led to a diagnosis of ectopic pregnancy, whereas falling hCG levels in the other two led to a presumptive diagnosis of complete abortion, possibly tubal pregnancy in light of the lack of vaginal bleeding. CONCLUSION: Pre-abortion sonography eliminates inadvertent second-trimester cases, and immediate postoperative examination of curettage material expedites the diagnosis of ectopic pregnancy when present.     

Pelvic spleen masquerading as an ovarian neoplasm

A case of a 53-year-old perimenopausal woman who presented with an 18-month history of irregular vaginal bleeding is reported. Vaginal ultrasonography revealed a 10 x 7 cm pelvic mass with an increased blood flow. Her serum CA125 was within the normal range. At laparotomy a normal spleen was found within the pelvic cavity.     

Two methods of assessing pain intensity in English-speaking and Spanish-speaking emergency department patients

A 13-year-old girl underwent a right salpingo-o-ophorectomy and partial omentectomy for an ovarian tumor that on microscopic examination was a grade 1 immature teratoma. Mature glial implants were found in the omentum (Stage III). No additional treatment was given. Ten months later, grade 0 and grade 1 peritoneal glial implants were found on laparotomy. Chemotherapy with four cycles of vincristine/cisplatin/etoposide/bleomycin was administered. A second laparotomy 4 months later showed persistence of grade 0 and grade 1 peritoneal glial implants. The patient was well for the next 7 years, after which time she presented with a pelvic mass that on microscopic examination was a malignant neuroectodermal tumor resembling a glioblastoma multiforme. The tumor did not respond to debulking and chemotherapy, and the patient died 6 months later, 8 years after her initial presentation. This case represents the second report of malignant transformation of peritoneal glial implants.     

The inlay-graft technique to create papillae between implants

A 29 year-old woman presented with continuous metrorrhagia and a positive pregnancy test 3 1/2 months after vaginal birth. Transvaginal sonography showed a 3.5 x 4 x 4 cm mostly echogenic uterine mass with diffuse myometrial invasion in the right fundal region. Colour Doppler sonography revealed extensive low impedance flow in the periphery of the mass suggestive of a trophoblastic tumor. Histological examination of curettage specimens revealed a chorionic carcinoma. The tumor size as measured by magnetic resonance imaging correlated well with that by sonography. Trophoblastic disease after a normal pregnancy is rare. Early diagnosis can be facilitated by transvaginal colour Doppler sonography.     

Staff attitudes to oral health care. A comparative study of registered nurses, nursing assistants and home care aides

The diagnosis of early ectopic pregnancy remains challenging for the gynecologist. Although early detection of a suspected pregnancy has been facilitated by quantitative beta human chorionic gonadotropin studies and ultrasonography, a patient subgroup remains with an ambiguous presentation. In this group of patients, the clinician must rely on microscopic examination of products of conception in a uterine curettage specimen to rule out the presence of an extrauterine pregnancy. The presence of an implantation site, chorionic villi, or trophoblastic tissue in uterine curettage samples is conventionally held as definitive evidence of an intrauterine pregnancy. We present a series of four cases that challenge this convention. In these cases, chorionic villi or an implantation site were identified in uterine samples of pregnant women who each ultimately proved to have an ectopic pregnancy. If clinical suspicion is high, the finding of either chorionic villi or an implantation site should not preclude further workup of a possible ectopic pregnancy. In cases where only a few villi or a single chorionic villus are identified, other signs of intrauterine implantation such as intermediate trophoblastic cells, hyalinized vessels, and a fibrinoid matrix should be sought to establish firmly the diagnosis of an intrauterine pregnancy.     

The association between Chlamydia trachomatis serology and pelvic damage in women with tubal ectopic gestations

OBJECTIVE: To determine whether pelvic damage is associated with positive Chlamydia trachomatis serology in women with tubal ectopic pregnancy. DESIGN: Cross-sectional retrospective study. SETTING: A prepaid health maintenance organization. PATIENTS: Two-hundred eighty-one women admitted with confirmed tubal ectopic pregnancy were interviewed for history of sexually transmitted diseases. Chlamydia serology was obtained for 135 subjects, and operative findings were available for 121 of these. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Pelvic damage, as determined by review of operative findings of the pelvis at the time of ectopic surgery. RESULTS: Pelvic damage was associated with positive chlamydia serology with an adjusted odds ratio of 4.2 (95% confidence interval: 1.8 to 9.7). Moderate and severe pelvic damage were more strongly associated with positive serology than mild damage. CONCLUSIONS: Women with ectopic pregnancies and antibodies to C. trachomatis are more likely to have damaged pelves than women with ectopic pregnancies without such antibodies. Prevention or early treatment of C. trachomatis infection may reduce pelvic damage and, therefore, reduce incidence of ectopic pregnancy.     

Primary torsion of the greater omentum mimicking duodenal ulcer

The diagnosis of primary torsion of the omentum is a diagnostic enigma and is made almost exclusively at laparotomy. The difficulty is enhanced when the patient has a chronic problem mimicking a specific entity, e.g. peptic ulcer disease. The case presented is an example of this situation. The patient's history and acute presentation were compatible with chronic peptic ulcer disease with acute perforation. At laparotomy, the findings of torsion of the right lower omentum with infarction, along with marked scarring of the remainder of the greater omentum explained the clinical picture. Torsion of the greater omentum, therefore, must be added to the list of differential diagnoses when one is considering peptic ulcer disease.     

Cervical pregnancy: an obstetric emergency. A clinical case

Cervical implantation could develop in three different ways. The gestational sac can grow up to external os and interruption may simulate an abnormal menstruation. Theoretically the gestational sac could reach the uterine cavity, with a normal evolution of the pregnancy, even if the implantation of the placenta would be on internal uterine os. Lastly, the ectopic gestational sac developes all in cervical channel with an "obstetrical catastrophe". The incidence of cervical pregnancy presents great differences between authors, from 1:1,000 to 1:95,000 pregnancies; this is due to the variability of diagnostic criteria. A 36 year-old woman, para 1001, came to the emergency unit with painless vaginal bleeding. She was pregnant at 8 weeks of amenorrhoea, and previously undergone a cesarean section. The portio was swollen and bluewish, the external os was opened. The uterus was slightly increased, expecially in the peri-isthmic area; no adnexal mass. The urinary hCG was < 15,000 I.U. An ultrasound examination showed the endometrium in decidual transformation, without identification of embrional or extraembrional structures. The diagnosis was retained miscarriage. During the cervical dilatation, an impressive and uncontrollable haemorrhage occurred. It was decided to perform a total hysterectomy via laparotomy. The macroscopic examination of the uterus showed the cavity empty and the sopravaginal cervical area enlarged, invaded by an ectopic trophoblastic proliferation. The majority of obstetricians will never see a cervical pregnancy; the minority who has to treat this pathology wishes to have never seen one.     

Gentamicin-resistant Staphylococcus aureus

The role of Arias-Stella reaction in diagnosis of ectopic pregnancy in a 35-year old woman who used a contraceptive coil in situ is described. The patient was seen with continuous uterine bleeding of almost 1 month duration. Histological examination of the curettage specimen showed multilayer endometrial epithelial cells with pyknotic apical nuclei and inflammatory infiltration of the stroma. These finding, trophoblastic growth and the absence of the chorion were indicative of the ectopic pregnancy. The patient was subjected to supravaginal hysterectomy. Examination of the surgery specimen confirmed diagnosis of tubal pregnancy.     

Analysis of blood flow in adnexal tumors by using color Doppler imaging and pulsed spectral analysis

Because of various contradictory reports in the literature and an increasingly urgent need for preoperative evaluation of adnexal masses before laparoscopic surgery, our aim was to disclose if examination by means of color Doppler ultrasound is useful in distinguishing benign from malignant adnexal tumors in our population. Prior to surgery, pulsed color Doppler velocimetry of the adnexal blood supply was performed in a prospective study in 80 patients with benign and 40 with malignant adnexal tumors. Vascularization was equally frequent in both groups of tumors. Blood vessels of benign tumors had a diffuse, intraseptal or intraproliferative location significantly more often and malignant tumor vessels more often exhibited a diffuse, intraseptal or intraproliferative location (p < 0.01). The mean value of RI+/-SD was 0.56+/-0.14 in benign and 0.33+/-0.13 in malignant tumors. The differences in RI between benign and malignant tumors are statistically significant (p < 0.01). In detecting malignant adnexal tumors, the sensitivity of RI < or = 0.40 is 82%, its specificity 97%, positive predictive value 94%, negative predictive value 92% and its accuracy 92%. The analysis of vascularization presence seems not to have any value in predicting the nature of adnexal tumors, and blood vessels arrangement, as well as measured RI < or = 0.40, allows us to predict the presence of malignancy with limited reliability.     

Transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma

OBJECTIVE: To assess the role of transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma. DESIGN: Prospective study with pathological confirmation of the diagnosis. SETTING: Department of Obstetrics and Gynecology of the University of Cagliari, Italy. PATIENTS: One hundred one consecutive premenopausal nonpregnant women submitted to laparoscopy or laparotomy, from November 1993 to October 1994, because of the presence of an adnexal mass. INTERVENTIONS: Within 2 days before surgery all patients underwent transvaginal ultrasonography and evaluation of CA-125 plasma levels. The ultrasonographic impression and the CA-125 value were then compared with the histopathological diagnosis. MAIN OUTCOME MEASURE: The overall agreement between the test result and the actual outcome was calculated using the kappa index for the transvaginal ultrasonography used alone and for the combination of transvaginal ultrasonography and CA-125 values, for each chosen cutoff and range. RESULTS: Transvaginal ultrasonography has a strong agreement between test and surgery (kappa value 0.76) whereas the combined use of the two methods is associated with a lower kappa index, ranging from 0.40 to 0.69. CONCLUSION: Transvaginal ultrasonography used alone has a better predictive capacity in differentiating endometrioma from other adnexal masses than combined methods.