Spontaneous Hemoperitoneum in Pregnancy: Masquerading as Acute Appendicitis.

Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare obstetric emergency that may have an adverse outcome for the mother and baby. This case report describes a unique SHiP case initially diagnosed as acute appendicitis in a patient with severe endometriosis before conception. A woman in her 30s, a primigravida, was admitted with abdominal pain at 32+5 weeks gestational age. Following a surgical review, she was initially diagnosed with acute appendicitis and commenced on intravenous antibiotics. She experienced a dramatic deterioration in her health in the form of clinical shock and fetal distress. She had an emergency laparotomy, a hysterectomy, and a left salpingo-oophorectomy for uncontrollable bleeding. The baby was born in good health, and the mother had an uneventful recovery.

Mid-gut volvulus and mesenteric vessel thrombosis in pregnancy: case report and literature review.

BACKGROUND: Mid-gut volvulus is a rare complication of pregnancy, where torsion of the small bowel around its mesentery can result in extensive bowel infarction. To our knowledge, there has been no previous reported case of mid-gut volvulus and mesenteric vessel thrombosis managed without bowel resection. CASE: A 25-year-old woman presented at 35 + 3 weeks gestation with constant abdominal pain. There was no past medical history of abdominal surgery. The patient later developed feculent vomiting. Exploratory laparotomy revealed a mid-gut volvulus causing small bowel ischaemia, which extended from the duodenojejunal (DJ) flexure to the terminal ileum. There was also mesenteric arterial and venous thrombosis. A healthy baby girl was delivered by caesarean section and the mid-gut volvulus was reduced. Further, two re-look laparotomies confirmed viable bowel following detorsion. The mesenteric vessel thrombosis was treated with intravenous heparin. The patient went on to make a full recovery. CONCLUSIONS: As shown in this case, the volvulus and mesenteric vessel thrombosis may occur during pregnancy even in patients without previous history of coagulopathies and abdominal surgery. It is difficult to make a clinical diagnosis, as the symptoms, physical signs and laboratory findings can be misleading. Therefore, a high index of suspicion is necessary for the early diagnosis of these conditions, as prompt treatment can prevent bowel resection and improve maternal and foetal outcomes.

Isloated tubal torsion in a fourteen year old girl.

Isolated torsion of fallopian tube is a rare event and often difficult to diagnose. This report describes such a condition in a patient who presented with pain lower abdomen and underwent laproscopy primarily by surgeons with the suspicion of appendicitis but eventually ended up in right salpingectomy because of isolated right tubal torsion. The issue of future fertility was obviously considered but unfortunately the tube could not be preserved because of necrosis and haemorrhage inside it. Tubal torsion should however be kept in mind in the differential diagnosis of lower abdominal pain in women of all ages.

Retroperitoneal haematomas in obstetrics: literature review.

INTRODUCTION: There is paucity of literature on retroperitoneal haemorrhage/haematomas (RH) as these cases are extremely rare in obstetrics. Experience is available mostly from case reports and therefore the incidence of RH in obstetrics is unknown. METHODS: Literature search in Medline/Pubmed and Google scholar using MeSH; aneurysm, haematoma, haemorrhage, obstetrics and retroperitoneal. AETIOLOGY AND PATHOGENESIS: This article discusses aetiology, pathogenesis, diagnostic difficulties and dilemmas, as well as misleading symptoms that often mimic common clinical conditions. DIAGNOSIS AND MANAGEMENT: Management of RH is complex and continues to improve with advancements in the investigative strategies, treatment options and critical care specialty. Further the authors highlight the importance of basic principles of clinical examination, the need for multidisciplinary input and the current trend in the management options.

Bali Belly: Salmonella senftenberg Found in an Infected Ovarian Endometrioma.

Salmonella is an extremely rare cause of an infected endometrioma. We present a case of a 30-year-old immunocompetent woman presenting with fevers and abdominal pain, on a background of prior endometriosis. Initial antibiotic treatment for pelvic inflammatory disease failed, and the patient progressed to septic shock requiring surgical evacuation of an infected ovarian endometrioma. Microbiological samples from stool, ovary, and peritoneal fluid revealed infection with Salmonella senftenberg. The likely diagnosis was Salmonella enterocolitis with bacterial translocation to an ovarian endometrioma.

Maternal morbidity and mortality associated with retroperitoneal haematomas in pregnancy.

Retroperitoneal haematomas in obstetrics are uncommon. The causes and pathogenesis of retroperitoneal haematomas lack clarity and the aim of this review is to recognise retroperitoneal haematomas as a separate entity from commonly seen vaginal and pelvic haematomas. It is time to raise awareness among obstetricians to recognise retroperitoneal haematomas as an important cause of maternal morbidity and mortality which requires high clinical suspicion and multidisciplinary input. As retroperitoneal haematomas are rare but can cause serious threat to maternal wellbeing, resources should be directed towards their management. Existing guidelines of maternal collapse and morbidity during pregnancy and puerperium need to include retroperitoneal haematomas as one of the important causes of maternal shock or morbidity. New learning pathways should be opted for to increase awareness of retroperitoneal haematomas among obstetricians enabling them to reflect on their implications while managing retroperitoneal haematomas. Management of retroperitoneal haematomas is complex and continues to improve with advancements in the investigative strategies, treatment options and multidisciplinary involvement.

Endometriosis Nodule Causing Spontaneous Haemoperitoneum in Pregnancy: A Case Report and Literature Review.

Spontaneous haemoperitoneum in pregnancy (SHiP) due to endometriosis is a very rare condition and this is a case of a 41-year-old primigravida, who presented at 32 weeks with sudden onset of severe lower abdominal pain without any uterine activity. This was a dichorionic-diamniotic twin pregnancy, following in vitro fertilisation for subfertility secondary to severe endometriosis. On admission, pain score was eight, with ten being the maximum of the scale. The vital signs were stable. Abdominal palpation revealed generalised tenderness with no guarding or palpable contraction. There was no evidence of bleeding and the cervical os was closed on speculum examination. The cardiotocograph (CTG) was pathological and a plan was made to deliver the babies with emergency caesarean section. Intraoperatively, there was massive haemoperitoneum which was managed successfully with the involvement of multidisciplinary input from general surgeons and urologists with optimum maternal and fetal outcome.

Expectant management of miscarriage in view of NICE Guideline 154.

Objective. To find out the success rate of conservative management of complete two weeks for miscarriage in view of NICE Guideline 154. Design. Prospective observational study. Setting. Early pregnancy assessment units of District General Hospital in the United Kingdom. Participants. Women of less than 14 weeks' gestation, with a diagnosis of miscarriage (missed miscarriage/anembryonic or incomplete miscarriage). Interventions. Expectant management for two weeks. Main Outcome Measure. (1) Efficacy of 2-week expectant management, that is, complete resolution of miscarriage based either on self-reporting of patient after passing products of conception at home between D0 and D14 of expectant management or confirmation on scan at D14, and (2) short-term complications needing strong analgesia, blood transfusion, and antibiotics. Results. Expectant management of miscarriage for 2 weeks from the day of diagnosis was successful in 58% (64 /111) and failed in 42% (47/111). Conclusions. Expectant management success rate is consistent with the results from the longitudinal studies and RCTs published in the past. It is a safe option as none of the patients on expectant/medical management needed strong analgesia/antibiotics or blood transfusion.

TORCH screening in polyhydramnios: an observational study.

AIM: The aim of this study was to understand the TORCH test and to evaluate its significance in women with polyhydramnios in singleton pregnancies. METHOD: Retrospective analysis of indications and results of TORCH referrals made from November 2007 to 2009 with detailed review of case notes of women with polyhydramnios who had TORCH test. RESULTS: The total number of deliveries during specimen time was 3004, out of which 110(3.6%) had serum TORCH screening. The main indication for this test was polyhydramnios 62 (56.36%) followed by obstetric cholestasis 20 (18.18%), Intra-uterine fetal demise 6 (5.45%), fetal anomalies 5(4.54%), and deranged liver function tests (LFTs) 2 (1.8%). 15 (13.6%) women had TORCH screening for other indications such as clinical polyhydramnios, increased nuchal translucency (>2.5 mm). cytomegalovirus (CMV) and toxoplasmosis antibodies were tested in all cases whereas, parvovirus and herpes simplex virus screen were carried out in 4 (12.7%) and 2 (1.8%) patients, respectively. One woman (0.09%) had infection with CMV who had TORCH screening carried out for deranged LFTs. None of these women had positive TORCH screening giving the p value of <0.0001. These women also did not have any associated perinatal or maternal mortality. CONCLUSIONS: While the sample size of this study is small to disregard the significance of TORCH test in polyhydramnios, the statistical evaluation shows that this test is not beneficial in women in whom polyhydramnios is an isolated ultrasound finding, especially when it is diagnosed in third trimester.