Failure to diagnose: ectopic pregnancy.

Case histories are based on actual medical negligence claims, however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. Medical negligence claims alleging 'failure to diagnose' are a common cause of claims and complaints against general practitioners. This article outlines strategies to minimise the possibility of an adverse patient outcome arising out of a delay in diagnosis of ectopic pregnancy.

Cost-effectiveness of presumptively medically treating women at risk for ectopic pregnancy compared with first performing a dilatation and curettage.

OBJECTIVE: To compare the cost and complication rate of two alternative strategies for the diagnosis and medical management of ectopic pregnancy when ultrasound is nondiagnostic. DESIGN: A decision tree was constructed to compare [1] dilatation and curettage (D&C) followed by treatment of all ectopic pregnancies with methotrexate versus [2] empiric treatment of all patients with possible ectopic pregnancies with methotrexate without D&C. SETTING: University setting. PATIENT(S): Ten thousand hypothetical women with nonviable pregnancies and a known incidence of ectopic pregnancy were entered into a computer model. MAIN OUTCOME MEASURE(S): The two approaches were compared with respect to the number of missed ectopic pregnancies, complications, procedures performed, admissions to the hospital, and cost. RESULT(S): The D&C group had 1% more failed managements of ectopic pregnancies and 13.4% fewer patients with a miscarriage undergo a second treatment for resolution. The D&C group had 13.7% fewer complications including 6.3% fewer hospitalizations. D&C costs $173 to $223 more than empiric use of methotrexate per patient. CONCLUSION(S): Empirically treating women at risk for ectopic pregnancy with methotrexate does not reduce complications or save money. In the absence of such savings, the desire to make an accurate and definitive diagnosis, allowing objective prognosis on future fertility and risk of repeat ectopic pregnancy, supports the need to distinguish a miscarriage from ectopic pregnancy before treatment with methotrexate.

Primary omental pregnancy: case report.

Omental pregnancy is a very rare form of ectopic pregnancy. Here we presented a case of primary omental pregnancy diagnosed at surgical exploration. A 28 year old woman submitted with severe abdominal pain, without any delay of menstruation. History of the patient revealed no use of contraceptive method. There was no gestational sac in the endometrial cavity and no tubal ring in the adnexa, but free peritoneal fluid in the pouch of Douglas was detected at ultrasonography. Laparotomy was done according to pre-operative diagnosis of ruptured tubal pregnancy. Bilateral tubes and ovaries were intact; omental pregnancy was detected and partial omentectomy was performed. Although 16 cases of omental pregnancy (mostly secondary) were reported in the literature, herein we describe a primary omental pregnancy without adnexial involvement.

Ruptured ectopic pregnancy presenting as an irreducible inguinal hernia.

An inguinal hernia that suddenly becomes irreducible may be secondary to a variety of other underlying conditions which can occasionally mislead the attending surgeon. Benign, inflammatory or neoplastic processes, as well as surgical emergencies such as intraperitoneal or retroperitoneal haemorrhage, have all been previously reported to mimic an inguinal hernia that suddenly becomes irreducible with or without clinical features of strangulation. We add an additional interesting presentation to this list in the form of a ruptured ectopic pregnancy, which is the first such case reported in the literature. A swelling in the groin may be much more complicated than it seems on superficial consideration and good clinical acumen is constantly required in managing such cases if a satisfactory outcome without any morbidity is to be expected.

Unexpected causes of gynecological pelvic pain.

During our day-to-day practice, we, as clinicians, occasionally come across patients whose symptomatology is atypical. In major teaching hospitals, it is usually easy to consult with other specialists to optimize patient management and standard of care. Our study patients were treated by the authors between January 1998 and January 2003. In this article, the authors report on 6 different cases of unexpected causes of pelvic pain, all of which were managed in a general gynecological unit at a major tertiary referral institution.

Characterizing ectopic pregnancies that rupture despite treatment with methotrexate.

OBJECTIVE: To identify risk factors for tubal rupture among ectopic pregnancies treated with methotrexate (MTX). DESIGN: Retrospective case-control analysis. SETTING: An urban medical center. PATIENT(S): Eighty-one women diagnosed with an ectopic gestation treated with MTX: 19 patients experienced subsequent tubal rupture, and 62 patients experienced ectopic resolution. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Predictive variables including serial human chorionic gonadotropin (hCG) values. RESULT(S): The hCG incremental rate before as well as after MTX administration was positively associated with tubal rupture. HCG values prior to ectopic diagnosis that increased at least 66% over 48 hours and rising hCG values after treatment with methotrexate were independent predictors of tubal rupture. A disproportionate number (47%) of ectopic pregnancies that ruptured were located in the tubal isthmus. CONCLUSION(S): The hCG incremental rate both before and after MTX represents an independent risk factor for subsequent tubal rupture. Concentrations of hCG before ectopic diagnosis that increased at least 66% over 48 hours, or persistently rising hCG concentrations after treatment with MTX, may lower the threshold for surgical intervention. Implantation site may represent an unidentifiable risk factor for tubal rupture.

Primary ovarian pregnancy after postpartum bilateral tubal ligation: a case report.

BACKGROUND: Primary ovarian pregnancy constitutes <1% of ectopic gestations. Likewise, bilateral tubal ligation failure is uncommon, occurring in approximately 1% of tubal sterilization procedures. Should pregnancy occur after bilateral tubal ligation, of every 3 such pregnancies, 1 will be an ectopic. The incidence of ovarian pregnancy after tubal ligation has not been reported, but must be extremely rare. CASE: A 30-year-old, breast-feeding, white woman 6 months postpartum, with bilateral tubal ligation after delivery, developed acute right lower quadrant pain while excercising. Evaluation in the emergency room revealed rebound tenderness in the lower right abdomen, a positive beta-hCG level and ultrasound findings suspicious for a right ectopic pregnancy. Exploratory laparotomy revealed hemoperitoneum, previously ligated but otherwise-normal-appearing fallopian tubes, and a ruptured and bleeding right ovary. The pelvis was otherwise normal. Histology of the right ovarian wedge resection showed chorionic villi consistent with ovarian pregnancy. Both fallopian tubes were religated, and a review of the original tubal ligation histology confirmed tubal lumen in both segments. CONCLUSION: While ectopic pregnancy is a known but rare risk of failed tubal sterilization, pregnancy involving the fallopian tube is usually reported after tubal ligation failure. The rarely seen primary ovarian pregnancy is usually associated with intrauterine contraceptive devices or occurs in patients with pelvic inflammatory disease. Ovarian pregnancies are associated with massive hemoperitoneum in women unaware that they are pregnant.

Persistent tubal pregnancy presenting with delayed hemorrhage from a second implantation of trophoblast on the ovary: a case report.

BACKGROUND: The use of conservative surgical techniques to treat ectopic pregnancies has been reported to increase the rate of incomplete trophoblastic tissue removal and subsequent regrowth. CASE: A persistent ectopic pregnancy occurred in a woman previously treated with laparoscopic linear salpingostomy for an ampullary ectopic pregnancy. Repeat laparoscopy was performed, and bleeding from an ovarian implantation site was treated with resection of the trophoblastic site and electrocautery. A repeat linear salpingostomy was also performed at the site of the prior salpingostomy, where trophoblastic tissue also persisted. CONCLUSION: This is the first known case of hemorrhage from the probable secondary ovarian implantation of persistent trophoblastic tissue. A repeat conservative surgical procedure to treat persistent ectopic pregnancies and maintain potential fertility is advocated. This case also serves as a reminder to diligently examine all areas of the pelvis for the possible secondary implantation of persistent trophoblastic tissue should reoperation be necessary.

[Splenosis and pelvic pain. A report of a case and literature review]. / Esplenosis y dolor pélvico. Reporte de un caso y revisión de la literatura.

Initially described by Buchbinder and Lipkoff in 1929, esplenosis is the transplant of the splenic heterotopy weave in the abdominal cavity. It is observed after the splenic traumatic rupture and appendectomy. It occurs also during the embryonic development. The most frequent places where it takes place are: the intrathoraxic cavity, intraperitoneal, retroperitoneo, and brain. Although the presence of this ectopic splenic weave is symptomatic, this pathology can be evident by pain in the pelvis or it can be confused with other pathologies such as hemangiomas of intestine, and endometriosis including metastasis carcinoma. It is impossible to predict which patients will develop the splenosis after the splenic trauma. The time of rupture or damage of the splectonomy and the amount of blood in the peritoneal cavity are not related with the number of implants. The symptoms are the clue. When the splenosis is diagnosed incidentally in a symptomatic patient, the complete surgery removal is not indicated. However this surgery is recommended when the abdominal pain or the diagnosis is uncertain. In this paper a case with a secondary pelvic pain, probably due to a tubaric abortion, agreeing with secondary splenosis and a traumatic splenic rupture, is reported.

Intramural pregnancy: a report of 2 cases.

BACKGROUND: Intramural pregnancy is a rare type of ectopic pregnancy and may be easily misdiagnosed as cornual pregnancy or trophoblastic tumor. Hysterectomy is performed due to extensive bleeding and uterine rupture in most cases. The incidence is <1% of ectopic pregnancy. Eighteen cases were reported in the People's Republic of China and 33 in the rest of the world since 1957. For a young woman who wishes to maintain her fertility, it is important to make an early diagnosis and to undertake conservative treatment. CASES: A 29-year-old woman, gravida 3, para 1, was admitted because of missed periods for >70 days, 1 week of mild vaginal bleeding and lower abdominal pain. Her serum beta-human chorionic gonadotropin (beta-hCG) level was 765 U/L. Transvaginal sonography (TVS) revealed an ill-defined mass measuring 3.0 x 3.5 x 2.0 cm within the fundal myometrium adjacent to the covering. At laparotomy, a mass 3 cm in diameter bulged from the left fundal covering and was resected to the surface of myometrium. The patient preserved her fertility through successful repair of the uterus. A 39-year-old woman, gravida 4, para 1, was admitted because of irregular vaginal bleeding for 2 months after intrauterine device insertion. Her serum beta-hCG level was 228 U/L. TVS revealed amorphous echoes in the uterine cavity. We made an initial, presumptive diagnosis of incomplete abortion. Curettage was performed, but no fetal elements were found. The serum beta-hCG level was 360 U/L after 1 week. Computed tomography revealed a trophoblastic tumor with deep invasion of the myometrium. A subradical abdominal hysterectomy was performed and gave the impression of chorionic carcinoma. Pathologic examination revealed diffuse hemorrhage and early invasion of chorionic villi in the fundal myometrium with focal decidual reaction of the endometrium. The diagnosis of intramural pregnancy was made after the operation. CONCLUSION: Both cases of intramural pregnancy were treated successfully.

An unusual cause of urinary retention in early pregnancy.

Urinary retention is a rare complication of early pregnancy with few serious sequelae. A Medline search found no association between urinary symptoms and cervical pregnancy. This case describes urinary retention resulting from a cervical pregnancy and describes a proposed mechanism to explain the presenting symptoms. Cervical pregnancy should be considered as a rare cause of acute retention of urine in early pregnancy, especially in the presence of vaginal bleeding.

Heterotopic pregnancy after in vitro fertilization-embryo transfer.

OBJECTIVE: A ruptured cornual pregnancy is a rare and challenging problem. We present two cases of cornual pregnancies after in vitro fertilization and embryo transfer (IVF-ET) treated by cornual resection, with an excellent perinatal outcome for the intrauterine pregnancy in both cases. A literature review of cornual pregnancy after IVF-ET is also included. CASE REPORTS: Two women had undergone IVF-ET because of tubal problems. Emergent laparotomy was performed because of internal bleeding at 12 weeks of gestation in one case and 17 weeks in the other, and in both cases, ruptured cornual pregnancies were found. Cornual resection and primary repair were performed. The women were discharged on the 6th and 7th postoperative day, respectively, and they underwent an elective cesarean delivery at 37 weeks of pregnancy. They were delivered of healthy babies, one weighing 2700 g and the other 2310 g. CONCLUSION: These cases illustrate that good perinatal outcomes can be achieved by surgical intervention in heterotopic pregnancies, even in the event of a ruptured cornu.