Presentation of a Rare Case of Acute Cholecystitis in the Last Trimester of Pregnancy Misdiagnosed As Acute Gastroenteritis: A Brief Review From Symptoms to Diagnosis and Effective Management of the Disease in Pregnant Women.

This case presentation involves a 31-year-old pregnant woman (gravida 2, para 1) in her 33rd week of pregnancy, who presented to the Emergency Department of General Hospital of Trikala, in Greece, complaining of 24-hour abdominal pain, vomiting, and diarrheal stools. With a possible initial diagnosis of acute gastroenteritis, it was decided to admit the pregnant woman to the Obstetrics and Gynecology Department. Abdominal ultrasound revealed thickening of the gallbladder wall without the presence of gallstones or distension of the intrahepatic and extrahepatic bile ducts. Clinical examination by a surgical team, combined with ultrasound and laboratory findings, established the diagnosis of acute cholecystitis. After successful conservative antibiotic treatment, the patient was discharged from the department on the fifth day of hospitalization. She underwent laparoscopic cholecystectomy during the puerperal period. In this paper, after describing a case of acute cholecystitis in pregnancy, we highlight the significant diagnostic difficulties and therapeutic dilemmas regarding the management of these patients, including their reluctance to use invasive diagnostic methods and their concerns about the teratogenicity of administered drugs.

A Case of Bilateral Transient Pregnancy-Related Osteoporosis of the Hip Diagnosed Late During the Lactation Period: A Rare Clinical Presentation and a Mini Review of the Literature.

Transient pregnancy-related osteoporosis of the hip is a rare, idiopathic, benign, and usually self-limiting condition caused by edema of the bone marrow, which can be visualized on magnetic resonance imaging. Bilateral localization of the disease is even less common. Our case concerns a 31-year-old primigravida who, during the 35th week of pregnancy, was hospitalized at the Obstetrics and Gynecology Clinic of the General Hospital of Trikala with lumbar and hip pain. The pain gradually increased in intensity and was accompanied by severe movement limitation. No history of falls or injury was reported. Her personal history was unremarkable, and the course of the pregnancy was uneventful. A clinical examination by a team of orthopedic surgeons established a diagnosis of acute hip and back pain. Rest and administration of paracetamol did not improve her clinical condition. During the postpartum and lactation period, the lack of symptom relief led to the decision to further evaluate the patient. The diagnosis of pregnancy-related transient osteoporosis of both hips was established by magnetic resonance imaging. Immediate treatment with bisphosphonate medication after the discontinuation of breastfeeding led to a definitive remission of the symptoms three months later. In this study, after the case description, a brief literature review of this rare clinical entity is presented. Proper knowledge of this condition helps to provide the best possible short- and long-term prognostic outcomes for the mother, fetus, and newborn.

The Association of Systemic Endothelial Dysfunction With Diffuse Diabetic Macular Edema.

Our aim was to assess whether systemic endothelial dysfunction, evaluated non-invasively by flow mediated dilation (FMD), is associated with diabetic macular edema (DME) and to determine if it is further impaired in patients with diffuse-DME. Consecutive patients (n = 84) with type-2 diabetes mellitus (T2DM) and diabetic retinopathy were enrolled. DME was not present in 38 (non-DME) and present in 46 patients; 25 with focal and 21 with diffuse-DME. No differences were detected between DME and non-DME groups regarding the clinical and demographic characteristics, except for the age of T2DM initiation (lower in non-DME). FMD values were significantly impaired in DME compared with non-DME patients, even after adjustment for multiple covariates (3.56 ± 1.03 vs 4.57 ± 1.25%, P = .003). Among DME patients, no differences were found concerning the clinical and demographic data, while FMD levels were significantly lower in diffuse-DME patients, compared with the focal-DME ones, regardless of the impact several confounders (2.88 ± 0.65 vs 4.08 ± 0.95%, P = .002). It is noteworthy that FMD values of non-DME and focal-DME patients did not differ significantly (4.52 ± 1.24 vs 4.21 ± 1.06%, P = .307). Moreover, among DME patients, impaired FMD was an independent predictor of diffuse-DME (odds ratio: 0.06, 95% CI 0.01-0.47, P = .007).

Fibroepithelial Polyp of the Vagina With Torsion: A Difficult Diagnosis Based on Clinical and Morphological Findings of the Vaginal Lesion.

Vaginal fibroepithelial polyps are rare benign tumors of the mucosa of the anterior vaginal wall. In extremely rare cases, they may originate from the posterior vaginal wall or be complicated by torsion. Our case concerns a 63-year-old patient who presented to the gynecology outpatient clinic of the General Hospital of Trikala with minor vaginal bleeding. On vaginal examination, a large pedunculated painless hemorrhagic polypoid mass was noticed, originating from the posterior vaginal wall. A torsion of the pedunculated vaginal tumor was suspected, leading to its surgical excision with clear resection margins. Due to extensive tissue necrosis, accurate histological identification of the vaginal neoplasm was not possible. Histological examination excluded vaginal malignancy. Based predominantly on the clinical and morphological features of the vaginal lesion, a diagnosis of vaginal fibroepithelial polyp with torsion was made, acknowledging its limitations. The patient was discharged from the clinic the same afternoon following the surgery. Three months later, no recurrence of the lesion in the vaginal wall was noted. Following the case presentation, this paper provides a brief literature review of this rare entity, focusing on the diagnostic and therapeutic approaches.

Enhancing Fertility in the Same Cycle: A Case Report on Effects of Hysterosalpingo-Foam Sonography (HyFoSy) for a Couple With Mild Infertility.

Fertility issues are becoming increasingly prevalent, leading many couples to seek fertility treatment at specialized centers. Infertility is a diverse clinical condition, with multiple potential etiologic factors and variable severity in its manifestation. Regardless of the underlying factors and severity, routine fertility assessment rarely differs between cases, with an essential step being fallopian tube patency assessment. Hysterosalpingo-foam sonography (HyFoSy) is the latest available diagnostic technique to assess this parameter, offering robust results, with reduced intra-procedural pain and equipment requirements, in the convenience of the office setting. However, apart from its diagnostic value, HyFoSy has also demonstrated a therapeutic tubal flushing effect, that may be the decisive factor for couples with mild infertility to spontaneously conceive. In this report, we present the case of a couple with mild infertility, who managed to spontaneously conceive after a HyFoSy examination, and in fact within the same cycle.

Large Extracervical Posterior Pedunculated Leiomyoma of the Uterus With the Only Symptom of Chronic Low Back Pain From Radiculopathy: A Case Report.

Large extra cervical-type posterior subserosal leiomyomas originating from the cervix are extremely rare. Our case concerns the surgical treatment of a large posterior pedunculated subserosal extracervical leiomyoma of the uterus with extension to the retroperitoneal space, which was associated with chronic low back pain. A 45-year-old patient, without menstrual disorders and with a medical history of chronic low back pain with sciatica, was referred for gynecological evaluation. The gynecological examination revealed the presence of a large pelvic mass, which occupied the pouch of Douglas. Preoperative imaging confirmed the presence of a solid pelvic mass, but its origin could not be clarified. Neither transvaginal ultrasound nor MRI could establish the diagnosis of extracervical leiomyoma of the uterus. Based on the clinical and imaging findings, surgical management of the patient was decided with laparotomy. Intraoperatively, a large extracervical pedunculated leiomyoma was found, which originated from the posterior wall of the cervix and extended into the retroperitoneal space. An abdominal total hysterectomy and bilateral salpingo-oophorectomy were performed. The procedure had significant surgical difficulties. The postoperative course was uneventful. Three months after surgery, the patient reported relief of symptoms. This paper highlights a brief review of cervical leiomyomas, highlighting the important difficulties regarding the preoperative diagnosis and surgical management of these patients.

Hysteroscopic resection as a safe minimally invasive technique for the management of cornual pregnancy: A case report and literature review.

Hysteroscopic resection of ectopic cornual pregnancy following MRI imaging is a safe and effective treatment option without significantly impacting fertility potential or increasing the risk of future obstetrical complications.

Evaluation of Postpartum Midwifery Care in Greece Based on Patient-Reported Outcomes Using the MMAYpostpartum Questionnaire: A Cross-Sectional Study.

Background The midwife's role throughout pregnancy and delivery management is essential, with multiple healthcare systems even following a midwife-led model of care. Of particular interest is the improvement and optimisation of midwifery postpartum care, which in Greece is empirically known to have decreased in quality, both due to the economic crisis and the recent pandemic. Aims To collect patient-reported outcomes with regard to the quality of midwifery services in Greece, ascertain baseline patient characteristics that may affect quality assessment, identify key areas for improvement, and propose patient subgroups who would most benefit from more specialized care. Setting and design A prospective, cross-sectional, questionnaire-based survey using the Measurement of Midwifery quality postpartum (MMAYpostpartum) questionnaire was conducted in public and private postpartum care centers in Greece. Methods The MMAYpostpartum questionnaire was distributed to 316 eligible women who received postpartum midwifery care in a healthcare center in Greece during the past three years. Multivariate linear regression was performed to examine significant correlations between baseline parameters and questionnaire scores. Results Ultimately, 204 answers were collected and analyzed. The patient's mean age was 35.5 years, and the mean body mass index (BMI) was 23.5. Overall, submitted scores were lower than those observed in the literature. A statistically significant correlation between older age, delivery at a public hospital, a history of hospitalization during pregnancy, and a lower midwifery service score was demonstrated. No other factors had a statistically significant effect on the quality score. Conclusions Delivery at public healthcare centers, older maternal age, and a history of hospitalization during pregnancy are significant predictors of a lower perceived quality of midwifery care. Thus, such patient subgroups may constitute potential targets for more meticulous midwifery care when resource setting prohibits the overall improvement of quality. Further research is required to collect additional data on patient insight and to test the present observations in a clinical setting.

Spontaneous Pregnancy After Surgical Repair of Subseptate Uterus: A Case Report and Review of the Available Literature.

Septate uterus is the most common congenital uterine malformation. It has been associated with poor reproductive outcomes, such as infertility and recurrent miscarriage, in the context of both assisted and non-assisted reproduction, though the exact underlying pathophysiological reasons remain unclear. Diagnosis is based on two-dimensional and three-dimensional ultrasound, magnetic resonance imaging, or laparoscopic/hysteroscopic findings. Hysteroscopic repair of the uterine septum has been shown to confer several benefits to reproductive outcomes, though this fact remains in question, due to inconsistent and or low-quality evidence in the medical literature. An individualized approach to the treatment of infertility patients with septate uteri is imperative, given the plethora of possible underlying factors that may complicate management. In this report, we present the case of a patient with a subseptate uterus and a history of infertility, who, following hysteroscopic metroplasty, managed to conceive and ultimately successfully deliver a healthy child.

Delivery of a Healthy Child Through International Gestational Surrogacy 10 Years Following Female Fertility Preservation and In Vitro Fertilization (IVF) for Recurrent Breast Cancer: A Case Report.

Assisted reproduction technology (ART) has made considerable progress in recent years; in particular with regard to cryopreservation, long-term storage, successful thawing, and embryo transfer of cryopreserved embryos. Regarding gestational surrogacy, progress has been made in the areas of awareness, social acceptance, regulation, legislation, availability, streamlining, and optimization of cross-border care. The above is being highlighted in the current presentation of a particularly challenging and novel case. A 43-year-old woman visited our clinic in Greece, seeking international gestational surrogacy due to recurrent breast cancer which rendered her medically unfit for pregnancy. Ten years before her initial visit to our clinic the patient had undergone fertility preservation due to breast cancer, her oocytes had been fertilized with her husband's sperm, and the embryos were cryopreserved and stored in a fertility clinic based in the United Kingdom. The stored embryos were transported to Greece, thawed, and successfully implanted to the selected gestational surrogate. Following an uneventful pregnancy, the surrogate delivered a healthy girl. This successful outcome exemplified innovation, motivation, and hope and may represent a paradigm of team scientific excellence associated with positive patient outcomes. Furthermore, this case constitutes the successful culmination of major advances made in various different sectors of cross-border reproductive care; laboratory, clinical, legal, ethical, and logistical.

Surgical and Quality of Life Outcomes Following Robotic-Assisted (da Vinci) Laparoscopic Repair of Vesicovaginal Fistula: A Case Report and Video Demonstration.

This report presents the case of a 63-year-old woman who developed a vesicovaginal fistula as a complication of a previous total hysterectomy. The fistula was treated with the use of the da Vinci X surgical system by a multi-disciplinary operating team, including senior Robotic Urological and Gynecological Surgeons at St. Luke's Hospital in Thessaloniki, Greece. The patient was monitored up to 12 months post-op at the time of writing and she was asked to evaluate post-op quality of life using the SF-36 and ICIQ-SF-UI questionnaires. The robotic surgical procedure was completed successfully. The total operation duration was 105 minutes, without any intra-operative complications. The patient was hospitalized for two days and made a swift, uneventful recovery. Regarding the quality of life, the patient reported satisfactory improvement in almost every domain assessed compared to her pre-op assessment; an improvement that was maintained throughout the reported follow-up period. At the time of writing, the patient reports no long-term complications and satisfactory urinary continence. Robotic-assisted laparoscopic vesicovaginal fistula repair is an effective and safe treatment option for this rare complication, as indicated by both post-operative data and the patient's own self-evaluation in this report. Further research is warranted, focusing on refining the surgical technique and comparing this to other alternative methods aiming to further improve patient outcomes.

Adnexal Torsion of a Mature Cystic Ovarian Teratoma With Hemorrhagic Infarction Misdiagnosed As Pelvic Inflammatory Disease in a Perimenopausal Patient: A Case Report.

Mature cystic teratomas are common benign ovarian tumors. They usually occur in young women, less than 40 years old. Our case report concerns a patient of perimenopausal age who came to the hospital complaining about mild abdominal pain, fever below 37.8°C, and diarrhea. The patient had an intrauterine contraceptive device inserted. Based on the clinical findings and imaging, a possible diagnosis of pelvic inflammatory disease was set, and intravenous administration of broad-spectrum antibiotics started immediately. The decision for performing laparotomy was taken after the fact that the clinical condition and blood tests of the patient had shown no improvement. Intraoperatively, the presence of a large twisted ovarian mass with signs of total necrosis due to adnexal torsion was detected. A histological examination of the surgical specimen confirmed the diagnosis of mature cystic teratoma in the right ovary. The postoperative course was uneventful. The presentation of the case follows a brief literature review of this rare medical condition regarding the diagnostic and therapeutic approach of these patients.

Multi-Port Robotic-Assisted Laparoscopic Myomectomy: A Systematic Review and Meta-Analysis of Comparative Clinical and Fertility Outcomes.

BACKGROUND: Uterine fibroids are the most frequently diagnosed gynaecological tumours, and they often require surgical treatment (conventional laparoscopic myomectomy-CLM). The introduction and evolution of robotic-assisted laparoscopic myomectomy (RALM) in the early 2000s has expanded the range of minimally invasive options for the majority of cases. This study aims to compare RALM with CLM and abdominal myomectomy (AM). METHODS AND MATERIALS: Fifty-three eligible studies adhered to the pre-established inclusion criteria and were subsequently evaluated for risk of bias and statistical heterogeneity. RESULTS: The available comparative studies were compared using surgical outcomes, namely blood loss, complication rate, transfusion rate, operation duration, conversion to laparotomy, and length of hospitalisation. RALM was significantly superior to AM in all assessed parameters other than operation duration. RALM and CLM performed similarly in most parameters; however, RALM was associated with reduced intra-operative bleeding in patients with small fibroids and had lower rates of conversion to laparotomy, proving RALM as a safer overall approach. CONCLUSION: The robotic approach for surgical treatment of uterine fibroids is a safe, effective, and viable approach, which is constantly being improved and may soon acquire widespread adoption and prove to be superior to CLM in certain patient subgroups.

The Impact of Coronavirus Disease 2019 Pandemic on Female Patients Seeking or Undergoing Fertility Treatment in a Single In vitro Fertilisation Clinic in Greece: An International, Cross-sectional Study.

Background: The temporary delay in fertility treatments due to the coronavirus disease 2019 (COVID-19) pandemic, in combination with the imposed lockdowns, has created psychological distress and anxiety amongst infertile patients. Aims: The aim of this study was to evaluate how the pandemic has influenced assisted reproduction technology (ART) patients in Greece, during the second wave of the pandemic. An additional aim was to examine the effects of the pandemic on cross-border patients in particular, compared to national ones. Settings and Design: This study was a cross-sectional, questionnaire-based study, distributed to 409 patients of a single in vitro fertilisation (IVF) clinic in Greece, during the period between January until the end of April 2021. Materials and Methods: The survey was conducted online via E-mail and was distributed to national and international female patients of a single IVF clinic in Greece, who were undergoing ART treatment during the second wave of the COVID-19 pandemic. Patient participation was anonymous, and participants provided informed consent for collection and publication of data. Statistical Analysis Used: The mean values of baseline characteristics, along with answer percentages per questionnaire item, were calculated. Collected data were cross-tabulated, and the Chi-square test was used as a measurement of the differences between national and cross-border patients. A P value lower than 0.05 was considered statistically significant. All analyses were conducted using the SPSS Statistics software. Results: From 409 initial candidates, 106 women, with a mean age of 41.2 years, completed the questionnaire (26% response rate). The majority of national patients did not experience any delays in their fertility plans (62%), while cross-border patients experienced over 6 months of delays (54.7%). The main reason for fertility postponement was travel restrictions due to COVID-19 for cross-border patients (62.5%), while national patients cited additional reasons. The majority of patients experienced a degree of stress (65.2%) due to the delays, however were not fearful of COVID-19 infection (54.7%). Most patients were aware of the protective measures taken by IVF clinics (80.2%), and this was a determinant factor (71.7%) for their decision to restart their fertility treatment. Conclusion: The COVID-19 pandemic lockdowns had a significant emotional impact on patient receiving or undergoing ART treatment in Greece. This impact was more pronounced on cross-border patients. This highlights the need for continuation of ART care, with the appropriate protective measures, during the pandemic, as well as during similar times of crisis in the future.

Spontaneous Pregnancy in a Hysterosalpingo-Foam-Sonography (ΗyFoSy) Cycle: A Case Report and Review of the Available Literature.

Fallopian tube pathology is a very common cause of infertility for multiple couples worldwide. Tubal patency assessment is considered a crucial component of initial infertility evaluation with several evaluation tests available, such as hysterosalpingography (HSG), hysterosalpingo-contrast sonography (HyCoSy), and hysterosalpingo-foam sonography (HyFoSy), the latest tubal patency assessment, utilizing ultrasonography and a foam-based contrast agent. An additional side-benefit of these assessment tests is a fertility-enhancing effect, best studied with the application of HSG. In this report, we present a case of a 28-year-old woman with unexplained infertility who spontaneously conceived in the same menstrual cycle that the HyFoSy exam with ExEm® foam (ExEm Foam Inc., Nashville, Tennessee, United States) was performed, without any additional fertility enhancement interventions.

Pueperal Paratubal Cyst Torsion and Secondary Fallopian Tube Torsion Without Ovarian Involvement: A Case Report.

Paratubal cyst torsion accompanied by secondary isolated fallopian tube torsion without involvement of the ipsilateral ovary is rare. A similar case occurring in the postpartum period has not been reported to date in the English literature. Our case report concerns a pregnant multiparous woman in the 40th gestational week, without regular antenatal care attendance, who was urgently admitted to the maternity ward with pushing labour pains and gave birth with vaginal delivery. A few hours later, puerperant complained of worsening severe lower abdominal pain, accompanied by nausea, dizziness and vomiting, unresponsive to analgesic medication. Based on the clinical and ultrasound findings, the diagnosis of an ovarian cyst torsion was established, and it was decided to treat the patient with surgery and in particular with laparotomy. Intraoperatively, in the left parametrium, the presence of an ovoid mass with a brownish-red hue and a smooth outer surface was detected, along which the ipsilateral fallopian tube ran, without the involvement of the ovary. Histological examination of the surgical specimen confirmed the diagnosis of isolated fallopian tubal torsion with paratubal cyst. The postoperative course was uneventful. In this paper, based on modern data, a brief literature review of this rare nosological entity is attempted, regarding the diagnostic and therapeutic approach, the immediate application of which can ensure the best prognosis.

Surgical Treatment of a Rare Case of Ovarian Fibroma Associated With Elevated CA125 Levels in a Patient of Reproductive Age: A Case Report.

Small ovarian fibromas (< 10cm) associated with elevated serum CA125 levels are rarely encountered, particularly in women of reproductive age. We report a rare case diagnosed in a 35-year-old patient after adnexectomy for a solid ovarian mass of approximately 5cm in maximum diameter, accompanied by elevated serum CA125 levels. In preoperative evaluation, no signs of inflammation from the genital tract were found, and no medical history of endometriosis, uterine leiomyomas, or non-gynecological cancer was reported. Intraoperative frozen section biopsy of surgical specimen obtained from the ovarian tumor had negative evaluation for malignancy. Histological examination of the surgical specimen confirmed the diagnosis of ovarian fibroma. The postoperative course was uneventful. Two months after surgery, the blood serum CA125 levels were within normal ranges. The patient is assessed at regular intervals in the gynecology outpatient clinic. In this paper, based on the data of the modern literature, a brief review of this rare nosological entity is made.

Primary Large Broad Ligament Fibroid: A Challenge in Surgical Practice.

Primary broad ligament fibroids, whose surgical treatment is challenging, are extremely rare. Our case concerns the surgical treatment of a large broad ligament fibroid. A 48-year-old patient, asymptomatic and with a medical history of uterine leiomyomas, came to the gynecology outpatient clinic to undergo a routine gynecological examination. On bimanual pelvic examination, the presence of a painless palpable pelvic mass was found, without being able to clinically demarcate it. Computed tomography imaging confirmed the clinical suspicion of a pelvic mass. The pelvic mass was more consistent with the subserosal pedunculated fibroid of the uterine corpus, but the preoperative diagnosis of adnexal mass cannot be excluded. It was decided to surgical treatment of the patient with a total hysterectomy and bilateral salpingectomy-oophorectomy. Intraoperatively, the presence of a large intraligamental mass was detected. The uterus, cervix, and ovaries were normal but displaced by the tumor. After resection of the leiomyoma from the broad ligament, where it was not found to be connected to a vascular pedicle from the lateral wall of the uterine corpus or the cervix, total hysterectomy and bilateral salpingectomy-oophorectomy were performed, due to the necessary resection of the right fallopian tube and ovary and the extensive injuries in the area. The postoperative course was uneventful. In this paper, following the case presentation, a brief review of primary broad ligament fibroids is presented, emphasizing the significance of comprehensive preoperative planning in the challenging intraoperative management of these patients, who have an increased risk of intraoperative complications.

Surgical Treatment of a Large Post-cesarean Hematoma in the Retzius Space Accompanied by a Blood Coagulation Disorder: A Rare Case Report.

Hematoma in the Retzius space after a cesarean section is a rare complication. The Retzius space, also referred to as the prevesical or retropubic space, represents an extraperitoneal artificial cavity situated between the pubic symphysis and the bladder. In instances where conservative treatment involving vigilant monitoring along with analgesics and antibiotics or ultrasound-guided percutaneous puncture proves unsuccessful, re-operation becomes imperative. Our case report concerns a second-parity pregnant patient who underwent a cesarean section in the 39th gestational week. A decrease in hemoglobin level on the third postoperative day, combined with the onset of febrile infection, an increase in inflammatory markers, and the manifestation of lower abdominal pain, prompted a thorough investigation of the puerperant. Imaging revealed the existence of a hematoma in the Retzius space associated with a mild blood coagulation disorder. Subsequently, the unsuccessful outcome of the ultrasound-guided percutaneous puncture of the hematoma, combined with the persistence of clinico-laboratory findings, led to the decision to perform a re-laparotomy on the 10th postoperative day after the cesarean section. During the surgery, a large hematoma was identified in the Retzius space, extending below the rectus abdominis muscles. The procedure involved surgical drainage of the hematoma, meticulous hemostasis, and the placement of negative pressure drainage in the Retzius space. The patient was discharged from the clinic on the fifth postoperative day after re-operation. Ten days later, both blood tests and ultrasounds were without abnormal findings. In this paper, following the case presentation, a brief review is provided regarding the diagnostic and therapeutic approach of patients with hematoma in the Retzius space after cesarean section.

Uterine malignant leiomyosarcoma associated with high levels of serum beta-human chorionic gonadotropin: A case report.

We present the case of a 54-year-old woman diagnosed with uterine leiomyosarcoma that produced beta-human chorionic gonadotropin (ß-hCG), evident by both serum and immunohistologic examination. Based on this and similar cases from the available literature, ß-hCG-producing sarcomas tend to have poorer prognosis, indicating that ß-hCG could potentially be used as a marker of disease status and response to the therapy; however, this association is inconsistent and should be further investigated.