RESUMO
OBJECTIVE: To describe an effective two-step surgical approach for the management of cesarean scar ectopic pregnancies (CSEPs). CSEPs occur at an estimated frequency of 1 in 1,800 pregnancies, constituting approximately 6% of ectopic pregnancies in women with a history of prior cesarean delivery [1, 2]. Despite numerous recommended therapeutic approaches, the most effective treatment strategy remains uncertain [3]. DESIGN: We present an innovative double-step technique for the management of a patient with a CSEP involving hysteroscopic subchorionic injection of methotrexate (MTX), followed by laparoscopic resection of the residual gestational sac and simultaneous repair of the uterine defect. SETTING: Academic tertiary hospital. PATIENT: A 34-year-old G2P1001 with a history of prior cesarean section presented at 10 weeks of gestation. Ultrasound revealed a gestational sac within the niche of the previous cesarean scar, confirming the diagnosis of a CSEP. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus, among others), and other applicable sites. INTERVENTION: The initial treatment involved hysteroscopic administration of MTX within the placental intervillous spaces, ensuring precise medication delivery. The administered dose of MTX was 1 mg/kg. Following the normalization of beta-human chorionic gonadotrophin (ß-hCG) levels, laparoscopic resection of the remaining gestational sac and reconstruction of the uterine wall defect were performed. MAIN OUTCOME MEASURES: We have implemented a management strategy focusing on ectopic pregnancy removal and addressing defect revision. The hysteroscopic approach allows for a clear assessment of the ectopic pregnancy and facilitates precise MTX administration, enhancing its effectiveness by increasing drug concentration within the placental intervillous space. Delaying surgical repair until after the ß-hCG levels have decreased reduces the risk of excessive bleeding during the procedure, as lower ß-hCG levels are associated with reduced vascularity at the ectopic site. Subsequent laparoscopic resection allows for complete removal of the remaining products of conception and repair of the defect, preserving the uterus and restoring normal anatomy. Compared to other surgical approaches, our two-step approach enables a more precise evaluation of placental implantation, making it a highly effective surgical method. RESULTS: We successfully managed a CSEP using a double-step technique. This involved hysteroscopic injection of subchorionic MTX, followed by laparoscopic resection of the residual gestational sac. Concurrently, we repaired the uterine defect. Both procedures were performed in an outpatient setting without complications detected during or after treatment. At the follow-up visit, the patient reported good health, and subsequent ultrasound confirmed an empty isthmocele. CONCLUSION: This sequential hysteroscopic and laparoscopic approach represents a definitive and effective minimally invasive surgical option for the treatment of CSEP.
Assuntos
Abortivos não Esteroides , Cesárea , Cicatriz , Histeroscopia , Laparoscopia , Metotrexato , Gravidez Ectópica , Humanos , Feminino , Metotrexato/administração & dosagem , Gravidez , Gravidez Ectópica/cirurgia , Gravidez Ectópica/etiologia , Gravidez Ectópica/tratamento farmacológico , Gravidez Ectópica/diagnóstico , Histeroscopia/métodos , Cicatriz/etiologia , Cicatriz/cirurgia , Adulto , Cesárea/efeitos adversos , Abortivos não Esteroides/administração & dosagem , Laparoscopia/efeitos adversos , Saco Gestacional/cirurgia , Resultado do TratamentoRESUMO
Background: Rates of type II endometrial cancers (EC) are increasing in the United States, especially in minority women. The purpose of this project was to examine a primarily minority and low socioeconomic status patient population in a public hospital to identify risk factors associated with the finding of type II histology in endometrial biopsies (EMBs). Materials and Methods: A retrospective chart review was performed of patients who underwent an EMB between 2010 and 2016. Included patients were postmenopausal women older than 50 years with biopsy-proven EC. Basic demographic data were analyzed, along with indication for EMB and ultrasound findings. Statistics were completed using analysis of variance and logistic regression with significance set at p < 0.05. Results: Four hundred sixty-one EMB results were reviewed. Around 17.4% (n = 80) resulted in a diagnosis of EC, with 45% (n = 36) being type II histology. Average age was 62.5 (standard deviation [SD] = 7.63), and the majority (64%) were Hispanic. Type II malignancies were diagnosed in 17% of Caucasians, 41% of Hispanics, and 61% of blacks/Haitians (p = 0.03). Factors associated with type II tumors in univariable models included older age (odds ratio [OR] 1.10 [confidence interval; CI 1.03-1.18], p = 0.007), black/Haitian (vs. Caucasian) race (OR 8.75 [CI 0.86-88.70], p = 0.066), obesity (OR 0.39 [0.15-0.98], p = 0.044), and number of years since menopause (OR 1.06 [CI 1.01-1.12], p = 0.027), although none remained independently predictive in the multivariable analysis. Conclusion: This minority population of postmenopausal women with EC had a greater prevalence of type II histologies. Understanding this pattern may be helpful in expediting the workup for abnormal symptoms in these women and prompt a higher level of suspicion for EC.
Assuntos
Pós-Menopausa , Provedores de Redes de Segurança , Idoso , Biópsia , Haiti , Humanos , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Endometriosis is a common condition that occurs in 6-10% of all reproductive age women. This number increases to approximately 40% in women with infertility and nearly 75% in women with complaints of chronic pelvic pain. Endometriosis is characterized by the presence of endometrial glands and stroma outside the uterine cavity. The most common complaints associated with endometriosis are dysmenorrhea and pelvic pain; however, patients often present with a variety of symptoms and on occasion are asymptomatic. When presenting with haemorrhagic ascites, endometriosis mimics ovarian malignancy. Conservative medical treatment is a feasible management option, especially in young patients who desire to preserve fertility. This article aims to present an extremely rare presentation of endometriosis, haemorrhagic ascites, and a review of the associated literature.
RESUMO
OBJECTIVE: To describe the clinical characteristics and laparoscopic findings of a very uncommon presentation of a patient with endometriosis. DESIGN: Video presentation of case report (Canadian Task Force classification III). (The institutional review board of the Hospital Naval Pedro Mallo, Buenos Aires, Argentina, has ruled that approval was not required for the publication of this case report.) SETTING: Hospital. PATIENT(S): Thirty-two-year-old woman with endometriosis presenting with hemorrhagic ascites. INTERVENTION(S): We demonstrate the laparoscopic appearance of the peritoneal organs in the presence of massive hemoperitoneum and encapsulating peritonitis and also describe the diagnosis and management options of an uncommon clinical presentation of endometriosis. The patient is a 32-year-old woman, gravida 0, who presented with abdominal pain and ascites. Initially, she underwent exploratory laparotomy with drainage of 5 liters of ascites and excision of endometrial peritoneal implants. She then presented 4 months later with sudden worsening abdominal pain and distention, weight gain, bloating, and shortness of breath. A diagnostic laparoscopy was performed with the findings of over 10 liters of dark hemoperitoneum and diffuse pelviperitonitis with loose necrotic, easy to remove, dense peritoneal tissue. Patient was started on triptorelin acetate with great response. MAIN OUTCOME MEASURE(S): Resolution of the symptomatology secondary to hemorrhagic peritonitis. RESULT(S): Clinical improvement of symptomatology of a patient with endometriosis and hemorrhagic ascites. CONCLUSION(S): Endometriosis can have different clinical presentations. Endometriosis should be a differential diagnosis in women of reproductive age presenting with massive hemorrhagic ascites. Hemorrhagic ascites, considered an exceedingly rare clinical course of endometriosis, represents a challenge to the surgeon who is unfamiliar with this condition. Bilateral oophorectomy is the definitive treatment, but conservative therapy is indicated for women of childbearing age. Diagnostic laparoscopy with drainage of hemoperitoneum is a feasible option to obtain a pathology-confirmed diagnosis in patients presenting with hemoperitoneum secondary to pelvic endometriosis. Awareness of this condition will prevent unnecessary aggressive resection, as is commonly performed when the condition is confused with ovarian cancer.
Assuntos
Endometriose/complicações , Hemoperitônio/etiologia , Fibrose Peritoneal/etiologia , Adulto , Endometriose/diagnóstico por imagem , Endometriose/cirurgia , Feminino , Hemoperitônio/diagnóstico por imagem , Hemoperitônio/cirurgia , Humanos , Laparoscopia , Fibrose Peritoneal/diagnóstico por imagem , Fibrose Peritoneal/cirurgia , Recidiva , Resultado do Tratamento , Pamoato de Triptorrelina/uso terapêuticoAssuntos
Mola Hidatiforme/cirurgia , Neoplasias Uterinas/cirurgia , Adulto , Feminino , Humanos , Histeroscopia , GravidezRESUMO
Objetivo: Evaluar la endocervicoscopia como técnica diagnóstica y terapéutica de las lesiones endocervicales más frecuentes. Métodos: Estudio prospectivo y descriptivo que incluyó 46 pacientes referidas para histeroscopia, entre agosto 2015 - enero 2016. Se plantea a las pacientes evaluación de cuello uterino para despistaje de infección por virus de papiloma humano. Se realiza colposcopia, citología, vaginohisteroscopia, instilación de 1,5 ml de ácido acético al 5 % en canal endocervical y reevaluación histeroscópica. Se recolectaron los hallazgos colposcópicos, endocervicoscópicos, citológicos y de anatomía patológica. Resultados: Hubo 31 pacientes (67,39 %) sin atipias colposcópicas y 15 (32,60 %) con atipias. En canal endocervical, 34 (73,91 %) sin atipias y 12 (26,08 %) con atipias (acetoblancas y papilomatosis). Otros hallazgos endocervicales: pólipos 12 (26,08 %), estenosis 7 (15,21 %), sinequias 7 (15,21 %). Resultados citológicos: 22 (47,82 %) resultados normales, 9 (19,56 %) lesiones de bajo grado, o atipias de significado incierto. Se tomaron 15 biopsias de exocérvix con asa, 13 (86,66 %) positivas para virus de papiloma humano y 12 biopsias de endocérvix con pinza de biopsia histeroscópica, de las cuales 11 (91,66 %) resultaron positivas para virus de papiloma humano. Conclusiones: Se encontró una incidencia de 26,08 % de lesiones atípicas endocervicales por virus de papiloma humano diagnosticadas por colposcopia y endocervicoscopia, siendo esta una técnica segura y de fácil ejecución en consultorio, que permite realizar evaluación precisa de las lesiones de la mucosa endocervical, permitiendo la toma de biopsia bajo visión directa, complementando de forma magistral a la colposcopia.
Objective: To evaluate endocervicoscopy as a diagnostic and therapeutic technique for the most frequent endocervical lesions. Methods: A prospective and descriptive study involving 46 patients referred for hysteroscopy between August 2015 and January 2016. Patients were assessed for cervical screening for screening for human papillomavirus infection. Colposcopy, cytology, vaginohysteroscopy, instillation of 1.5 ml of 5% acetic acid in the endocervical canal and hysteroscopic reevaluation were performed. The colposcopy, endocervicoscopic, cytological and pathological findings were collected. Results: There were 31 patients (67.39%) without colposcopic atypia and 15 (32.60%) with atypia. In the endocervical canal, 34 (73.91%) had no atypia and 12 (26.08%) had atypia (acetowhite and papillomatosis). Other endocervical findings: polyps 12 (26.08%), stenosis 7 (15.21%), synechia 7 (15.21%). Cytological results: 22 (47.82%) normal findings, 9 (19.56%) low grade lesions, or atypia of uncertain significance. Fifteen biopsies of exocervix with loop, 13 (86.66%) positive for human papillomavirus and 12 biopsies of endocervix with hysteroscopic biopsy had been taken, of which 11 (91.66%) were positive for human papillomavirus. Conclusions: An incidence of 26.08% of atypical endocervical lesions for human papillomavirus was found, which were diagnosed by colposcopy and endocervicoscopy, which is a safe and easy-to-perform technique in the office, which allows an accurate evaluation of the lesions of the endocervical mucosa, allowing the biopsy to be taken under direct vision, complementing in a masterful way the colposcopy.
RESUMO
We report a case of an abdominal gunshot wound in a third trimester pregnant woman. The fetus sustained a superficial skin injury, with survival of both mother and fetus. Conservative management was conducted successfully. Other management options are discussed.
Assuntos
Útero/lesões , Ferimentos por Arma de Fogo , Adulto , Parto Obstétrico , Feminino , Humanos , Recém-Nascido , Masculino , GravidezRESUMO
Determinar la posible relación entre características del lóbulo del pabellón auricular y la biotipatología del pie con la posibilidad de desarrollar preeclampsia. Ciudad Hospitalaria "Dr. Enrique Tejera" Valencia, Edo. Carabobo. Muestra elegida al azar de 263 pacientes dividida en 2 grupos: 58 primigestas en puerperio inmediato de embarazos no complicados con esta patología. Los resultados fueron sometidos a la prueba de Ch cuadrada (X²). Del grupo toxémico el 41,37 por ciento tenía lóbulo adherido y 58,63 por ciento lóbulo péndulo, en el grupo control 43,90 por ciento lóbulo adherido y 56,63 por ciento péndulo (p= 0,73 > 0,001 X²= 0,11). Se encontraron 102 primigrávidas con pie griego; 30,39 por ciento desarrolló preeclampsia y 60,61 por ciento no tuvo esa complicación, de las 161 con otro tipo de pie, se encontró un 16,77 por ciento de preeclámpticas y 83,22 por ciento sin dicha complicaciones (p= 0,0094 < 0,01 X²= 6,674). No existe relación entre las características del lóbulo del pabellón auricular y el desarrollo de preeclampsia. Las pacientes con pie de tipo griego tiene una incidencia mayor de preeclampsia