RETROUTERINE PERFORATED GANGRENOUS APPENDICITIS.

We present an atypical case of retrouterine gangrenous perforated appendicitis with Douglas abscess in a 33-year-old woman, with clinical picture developing over two weeks. Laparotomy and appendectomy with abdominal drainage and antibiosis were performed and resulted in complete recovery.

Appearance of uterine perforation by hysterosalpingography.

The appearance of a uterine perforation that occurred at the time of office hysteroscopy is shown via hysterosalpingogram and laparoscopy.

Trophoblastic tissue spread to the sigmoid colon after uterine perforation.

BACKGROUND: Trophoblastic tissue spread following uterine perforation during dilation and curettage is rare. We present a case of trophoblastic spread to the sigmoid colon following uterine perforation, which was treated by surgical removal of the implants and intramuscular administration of methotrexate. CASE: A woman presented 3 weeks after curettage for a blighted ovum. Laparotomy performed for suspected intra-abdominal bleeding revealed bleeding trophoblastic implants in a perforation tract and the anterior uterine wall and on the appendix epiploica of the sigmoid colon. The implants were surgically removed and methotrexate was administered for persistently high beta-hCG levels. The patient fully recovered. CONCLUSION: Extrauterine trophoblastic implants should be considered in women evaluated for abdominal pain whose pregnancy test is positive after uterine perforation. Conservative treatment with methotrexate in nonacute patients may be considered.

The management of the perforated uterus in conjunction with 1st trimester abortions.

PIP: The most dangerous sequelae to uterine perforation in pregnancy are: hemorrhage, damage to adjacent viscera, failure to heal properly, possible adhesion, and possible infection. Factors affecting the evaluation of these sequelae are influenced by the experience of the operator, the length of gestation, the time of occurrence during abortion, the type of instrument causing the perforation, the penetration of adjacent structures into the uterus, the location of the perforation site (requiring endoscopy, laparoscopy, or laparotomy), and the availability of adequate manpower and equipment for conservative management of this condition (nursing personnel, laboratory, and a ready operating room). Aggressive management means the exploration of the abdomen in all cases of perforation to ascertain the degree of injury. Conservative management avoids unnecessary surgery and awaits the indications for exploratory surgery without exploration of the patient unless blood loss or damage to adjacent structures is evident. A perforation should be suspected whenever an instrument is lost either sideways or longitudinally. The incidence of uterine perforations has been reported to be in the range of 1/250 to 1/1000 cases. However, this is a grossly underreported figure. In the Madison Avenue Hospital, Tuscaloosa, Alabama, 18 cases of early perforation (6-8 weeks) were brought back for dilatation and curettage 4 weeks after conservative management. Six of these required laparotomy due to repeat perforations. In the case of incomplete abortion in conjunction with a perforation only laparotomy can safety evacuate the uterus. Sharp curette or a suction tip curette can cause more serious injury than a blunt instrument. If adjacent organs are pulled into the uterus, laparotomy is necessary. Most cases require the abdomen irrigated of free blood, adequate hemostasis, reperitonealization of viscera, and no prophylactic antibiotics unless rheumatic heart disease, or chronic debilitating disease exist.^ieng