COVID-19 infection during pregnancy and risk of early and late spontaneous miscarriages: A matched case-control population-based study.

OBJECTIVES: To evaluate the effect of COVID-19 during the first trimester on the rate of first- and second-trimester miscarriages. Secondary aims include the effect on stillbirths and the correlation between symptom severity and pregnancy outcomes. METHODS: A retrospective matched case-control population-based study extracted data from electronic medical records of a nationwide database of the second largest healthcare organization that provides medical services to over 2 000 000 patients in Israel. Pregnancy outcomes in COVID-19-positive pregnant patients in 2020 were compared with an age- and gestational-week-matched 1:2 case-control cohort of pre-pandemic pregnant patients that received medical care in 2019. RESULTS: Of 68 485 pregnant women treated in 2020, 2333 were COVID-19-positive during pregnancy: 215 during the first trimester, 791 during the second trimester, and 1327 during the third trimester. We compared these data with the control cohort of 4580 pre-pandemic pregnant patients. The rate of spontaneous miscarriage was significantly higher 146/2187 (6.3%) in COVID-19-positive patients versus 214/4580 (4.7%), (P < 0.01, odds ratio 1.34, 95% confidence interval 1.094-1.691). Most miscarriages occurred during the first trimester in both groups, yet the rates were significantly higher in the study group (5.4% vs 3.8%, P < 0.01). There was no association between COVID-19 severity and miscarriage risk. CONCLUSION: COVID-19 diagnosis during early pregnancy increased the rate of spontaneous miscarriage in our cohort compared with an age- and gestational-week-matched pre-pandemic control group.

Isolated Fallopian Tube Torsion: An Underdiagnosed Entity with Debatable Management.

STUDY OBJECTIVE: To study features of isolated fallopian tube torsion (IFTT) to promote early diagnosis of this entity and describe options for management. DESIGN: Retrospective cohort study from October 2017 through October 2020. SETTING: Tertiary care hospital. PATIENTS: All patients with surgically confirmed adnexal torsion or IFTT during the study period. INTERVENTIONS: All of the patients underwent gynecological examination, imaging, and laparoscopy. MEASUREMENTS AND MAIN RESULTS: During this 3-year period, 64 patients underwent laparoscopy owing to confirmed torsion, of which 55 had adnexal torsion, and 9 had IFTT. Patients with IFTT tended to be younger (21.2 years ± 8.2 vs 29.1 years ± 11.9, p = .06) and had more fever on admission (p = .007). On ultrasound examination, isolated hydrosalpinx was demonstrated only in patients with IFTT (p <.001). During surgery, more para-ovarian cysts were observed in patients with IFTT (44.4% vs 10.9%, p = .01), whereas patients with adnexal torsion had more ovarian cysts (52.7% vs 0%, p = .003). The most common procedure was detorsion in both groups. Most patients that underwent detorsion of the tube had a normal ultrasound scan on follow-up examination. CONCLUSION: IFTT is probably underdiagnosed. Its clinical presentation is more equivocal than adnexal torsion, and ovaries are usually of normal size on ultrasonography. Hydrosalpinx or para-ovarian cysts should raise suspicion toward IFTT. Detorsion of the tube is probably a valid management option, although further research with long-term follow-up analyzing tubal patency is necessary to define the optimal management for this condition.

[GASTRIC CANCER IN PREGNANCY].

INTRODUCTION: Gastric carcinoma in pregnancy is rare and occurs in only 0.025% to 0.1% of all pregnancies. Due to it's symptoms of abdominal discomfort and nausea, which are common during pregnancy, the diagnosis is usually made in an advanced stage. We present a case of a 37 years old woman who presented at 18 weeks of gestation with abdominal pain, nausea and vomiting accompanied with severe maternal ascites. Her workup included an MRI scan, abdominal and obstetrical ultrasound scans, sampling of the peritoneal fluid, gastroscopy and diagnostic laparoscopy. She was diagnosed with a stage four gastric carcinoma. As seen in this case and in the current literature, diagnosis of gastric carcinoma in pregnancy is difficult. It often tends to be made in stage three or four and usually carries a very poor prognosis. In this paper, we describe our experience with this patient and review the literature.

A Pilot Study of Guided Conservative Hysteroscopic Evacuation of Early Miscarriage.

STUDY OBJECTIVE: To evaluate initial feasibility and experience with guided hysteroscopic morcellation for uterine evacuation of early miscarriage. DESIGN: A prospective pilot study of 10 cases. SETTING: A tertiary university hospital in Israel. PATIENTS: Women with confirmed early miscarriage at a gestational age of below 10 weeks from the last menstrual period. INTERVENTIONS: From May 2020 to October 2020, the hysteroscopic TruClear tissue removal system (Medtronic, Minneapolis, MN) was used for evacuation of early miscarriage in 10 women. The procedures were recorded. MEASUREMENTS AND MAIN RESULTS: Data including the length of the procedure, visibility, complete evacuation, bleeding, complications, and follow-up ultrasonography (US) were recorded. The mean duration of the procedure was 24 minutes. Complete evacuation was recorded in all cases. No adverse events were recorded in any of the 10 procedures. Normal uterine cavity without evidence of retained products of conception was documented in follow-up evaluation by US in all cases. Four patients underwent a follow-up office hysteroscopy that demonstrated a normal cavity without evidence of adhesions. In 4 cases (40%), an additional suction curettage was performed immediately after the hysteroscopic procedure owing to obscured visibility or an abnormal US scan at the end of the procedure. However, retained products of conception were found in only 1 of these 4 suction specimens (25%). CONCLUSION: Hysteroscopic morcellation under vision seems to be a safe and feasible technique for management of early missed abortion. This method may have potential as an innovative treatment of miscarriage in selected cases. Further studies are needed to refine the indications and the surgical technique.

Addition of Lidocaine to the Distension Medium in Hysteroscopy Decreases Pain during the Procedure-A Randomized Double-blind, Placebo-controlled Trial.

STUDY OBJECTIVE: To evaluate the effect of adding a local anesthetic to the distension medium in office diagnostic hysteroscopy using the vaginoscopic approach on pain during the procedure. Secondary aims included documenting side effects, patient satisfaction, and the time needed to complete the procedure. DESIGN: Randomized double-blind placebo-controlled study. SETTING: University-affiliated hospital; office hysteroscopy clinic. PATIENTS: Total of 100 patients who underwent office hysteroscopies divided in half with 50 in the intervention group and 50 in the control group. INTERVENTIONS: Ten mL of lidocaine 2% added to 1000 mL of saline solution that was used as the distension medium for hysteroscopy in the study group vs 1000 mL of saline alone in the control group. MEASUREMENTS AND MAIN RESULTS: A significant difference was found in the increment of pain as measured by visual analog scale after the hysteroscopy between the 2 groups. Patients receiving lidocaine had an average rise of 1.9 in the visual analog scale score after the procedure compared with 2.9 in the control group (p = .033). There was also a nonsignificant trend for shorter duration of hysteroscopy in the intervention group compared with the control group (180.1 vs 222.1 seconds, p = .08). Patients' satisfaction was high in both groups (98% for the study group and 92% for the control group). Success rates were also similar between the 2 groups at approximately 95%. No side effects were recorded in either group. CONCLUSION: The addition of local anesthetic to the distension medium in office hysteroscopy produces significant reduction in pain during the procedure without adding time to the procedure and without side effects.

Long-Term Ultrasound Follow-Up After Pediatric Adnexal Torsion.

PURPOSE: Conservative surgical management of adnexal torsion in pre- and post-menarchal girls by de-torsion and adnexal conservation is the current standard of care. The aim of this study is to investigate the long-term outcome of adnexal torsion in this population in terms of ultrasound appearance and ovarian volume. METHODS: Patients who were surgically treated for adnexal torsion and were < 18 years old at time of surgery were prospectively invited for ultrasound follow-up. The ultrasound exam included measurements of ovarian volume and grayscale appearance including identification of ovarian follicular activity. RESULTS: 84 cases of torsion in this population were identified, and 37 of them were included in the study. Of those, the affected ovary could not be demonstrated on follow-up scan in six (16.2 %) cases. A difference of ≥ 2 cm3 in ovarian volume between the affected and non-affected ovaries was diagnosed in 12 (32.4 %) cases, but follicular activity was observed in 10 of those. Thus, possible ovarian injury (including cases of non-demonstrated ovary and volume difference of ≥ 2 cm3 between the affected and non-affected ovaries) was found in 18 (48.6 %) cases. Of the clinical and surgical parameters (including age at time of torsion, duration of pain prior to admission, cystectomy procedure and intraoperative "bluish" appearance of the ovary), only the presence of fever on admission was significantly associated with possible ovarian injury (p = 0.01). CONCLUSION: Long-term ultrasound follow-up of pre- and post-menarchal girls with a history of adnexal torsion may identify patients with adversely affected ovarian volume. The significance of this finding in terms of fertility is unknown.

Two-step hysteroscopy for management of morbidly adherent retained products of conception.

PURPOSE: Retained products of conception (RPOC) may occur as the result of a morbidly adherent placenta. In these cases, the hysteroscopic removal of RPOC may be technically challenging, and may require more than one hysteroscopic procedure. We sought to compare the clinical, surgical, and postoperative characteristics of cases managed by either a one-step hysteroscopy procedure or a two-step hysteroscopy approach. METHODS: A retrospective review of all RPOC cases managed by hysteroscopy from 1/2013 to 3/2018. We included cases of RPOC occurring following delivery and medical or surgical pregnancy terminations. The rates of postoperative intrauterine adhesions were assessed by office hysteroscopy. RESULTS: A two-step procedure was required in 11 (3.9%) of the 358 women who underwent hysteroscopy for removal of RPOC during the study period. Comparison between the two-step and the one-step procedure groups revealed that the women in the two-step group were significantly older and the mean RPOC size was significantly larger (35.5 ± 4.1 years versus 30.7 ± 5.9 years, respectively, p = 0.01, and 38.6 ± 9.8 mm versus 22.3 ± 7.5 mm, p < 0.001, respectively). While the rates of intraoperative complications were similar between groups, readmission for postoperative fever was more common in the two-step group (18.2% versus 2.0%, respectively, p = 0.03). Postoperative intrauterine adhesions were diagnosed in 20.0% and 5.2%, respectively (p = 0.05). CONCLUSIONS: The two-step hysteroscopic approach enabled the complete removal of larger RPOC masses without the use of uterine curettage. The women who underwent the two-step procedure, however, were at increased risk for postoperative fever and postoperative intrauterine adhesions.

Laparoscopic Removal of an Abdominal Pregnancy in the Pelvic Sidewall.

STUDY OBJECTIVE: To describe the presentation, diagnosis, and management of a patient with abdominal pregnancy and to illustrate the laparoscopic technique used to manage this patient. DESIGN: A descriptive study approved by our local Institutional Review Board. Consent was given from the patient. SETTING: A university hospital in Ashdod, Israel. PATIENT: On May 15th 2018, a gravida 3, para 2, 37-year-old asymptomatic patient was referred to our hospital's gynecologic emergency department due to a suspected ectopic pregnancy. The patient had no relevant medical or surgical history. Her obstetric history consisted of 2 spontaneous vaginal deliveries with no other significant gynecologic history. Her menses were regular every month. Her last menstrual period was 6 weeks before presentation. Her ß-human chorionic gonadotropin (hCG) level measured on the day before presentation was 24,856 IU/L. Physical examination was unremarkable except for a small amount of brownish vaginal discharge. A transvaginal ultrasound (TVUS) exam on presentation did not demonstrate an intrauterine gestational sac, but revealed a gestational sac and a fetus next to the right adnexa, with a crown-rump length of 1.3 cm, consistent with 7+3 gestational weeks. There was a minimal amount of fluid in the pouch of Douglas. INTERVENTION: Owing to an extrauterine pregnancy with high ß-hCG value, laparoscopic operative management was chosen. On entrance to the abdominal cavity, a normal uterus and 2 ovaries and fallopian tubes were observed. A small to moderate amount of blood was present in the pouch of Douglas. a 3- to 4-cm distension was noted over the right uterosacral ligament. Following delicate probing of the area, moderate to severe bleeding commenced, which was initially controlled with local pressure and oxidized regenerated cellulose. An intraoperative TVUS identified an abdominal pregnancy in the right pelvic sidewall. The gestational sac was completely dissected and removed following ureterolysis and separation of the right ureter from the specimen. Local injection of vasopressin was also used. The ß-hCG level before surgery of 19,008 IU/L decreased to 6339 IU/L on postoperative day 1. The patient was discharged in good condition on postoperative day 2. A final histopathological report confirmed a gestational sac. MEASUREMENT AND MAIN RESULTS: This patient referred for a tubal ectopic pregnancy was eventually diagnosed with an abdominal pregnancy and was treated operatively with complete excision of the abdominal pregnancy, which was located at the right pelvic sidewall. CONCLUSION: Abdominal pregnancy is a rare type of ectopic pregnancy with a reported incidence of 1:10,000 to 1:30,000 pregnancies, and accounts for approximately 1% of ectopic pregnancies [1]. It carries a high risk for maternal morbidity and mortality. Many different locations at different gestational ages have been reported in the literature, including the pouch of Douglas, pelvic sidewall, bowel, broad ligament, omentum, and spleen [2-4]. These varied locations and the rarity of this type of pregnancy make diagnosis and treatment challenging. The location of the growing fetal tissue may endanger the patient's life if it impinges on vital anatomic structures. In the present case, the gestational sac was very close to the right ureter, and we opted to surgically excise the gestational sac in its entirety.

Prediction of Premalignant and Malignant Endometrial Polyps by Clinical and Hysteroscopic Features.

STUDY OBJECTIVE: To investigate whether hysteroscopic features can contribute to the diagnosis of malignancy in endometrial polyps. DESIGN: Retrospective review. SETTING: Obstetrics and gynecology department. PATIENTS: All women who underwent operative hysteroscopy for the removal of endometrial polyps between January 2012 and September 2017. Their medical records were reviewed, and information on medical, surgical, and obstetric history and hysteroscopic findings (including the number, size, and vascular appearance of the polyps) were abstracted. INTERVENTIONS: Operative hysteroscopy with resection or biopsy of endometrial polyps. MEASUREMENTS AND MAIN RESULTS: Five hundred fifty-six women were included in the study. Their mean age was 55.4 ± 12.4 years, and 322 (57.9%) were menopausal. Endometrial carcinoma was found in 26 (4.7%) cases, whereas endometrial hyperplasia was found in 5 (0.9%) cases. Endometrial carcinoma or hyperplasia was significantly associated with patients' age, menopausal status, increased polyp vascularity on hysteroscopy, and the presence of 3 or more polyps on hysteroscopy (p <.01 for all comparisons). However, the size of the largest polyp was not associated with endometrial carcinoma or hyperplasia. On logistic regression analysis, only increased polyp vascularity was associated with endometrial carcinoma or hyperplasia (odds ratio =13.5; 95% confidence interval, 5.6-32.3; p <.001). The sensitivity, specificity, positive predictive value, and negative predictive value of polyp vascularity for the diagnosis of polyps of nonbenign pathology were 51.6%, 94.3%, 34.8%, and 97.1%, respectively. CONCLUSION: Hysteroscopic findings of increased vascularity of endometrial polyps and numerous endometrial polyps may suggest the diagnosis of malignant polyps, in addition to demographic parameters such as age and menopausal status.

Retained products of conception: What is the risk for recurrence on subsequent pregnancies?

OBJECTIVE: To investigate whether women who were surgically treated for retained products of conception (RPOC) by either suction curettage or hysteroscopy are at risk for recurrent RPOC on their subsequent pregnancies. STUDY DESIGN: Retrospective analysis of 442 women surgically treated for RPOC following delivery or abortion by suction curettage (N = 63, 14.3%) or hysteroscopy (N = 379, 85.7%). Information on subsequent pregnancies and their outcomes was available for 161 (36.4%) women. RESULTS: One or more live births were reported for 150 (93.2%) of the women for whom information on subsequent pregnancies was available. The overall rate of spontaneous abortions was 31/161 (19.3%). Recurrent RPOC were diagnosed in 25 (15.5%) cases, while third stage of labor placental problems (including retained placenta or cotyledons and placenta accreta) were found in 44 (27.3%) cases. Recurrent RPOC was associated with treatment by suction curettage compared with hysteroscopy for the initial RPOC on multivariate logistic regression analysis (Odds Ratio [OR] = 3.6, 95% Confidence Interval [CI]1.3-10.5, p = 0.01) and with the initial RPOC occurring after delivery compared with after abortion (OR = 8.4, 95%CI 1.8-39.5, p = 0.006). CONCLUSION: Women treated for RPOC are at risk for recurrent RPOC and for third stage of labor placental problems on their subsequent pregnancies, especially those who had been managed by suction curettage in comparison with operative hysteroscopy. Clinical and ultrasound follow-up in the early and late postpartum period should be considered in women with a history of RPOC.

Postpartum Retained Products of Conception: A Novel Approach to Follow-Up and Early Diagnosis.

PURPOSE: To investigate whether ultrasound follow-up for the detection of postpartum retained products of conception (RPOC) in women considered at risk for this condition may allow for early diagnosis. METHODS: Parturients at risk for RPOC underwent an ultrasound exam on the second postpartum day. Based on the ultrasound findings, women were either: (1) discharged to routine postpartum care in cases of normal scans, (2) invited for follow-up in cases of abnormal scans. We retrospectively analyzed the rates of women requiring uterine evacuation due to persistent abnormal scans. RESULTS: 761 parturients (out of 17 010 deliveries, 4.5 %) were included. Of those, 490 (64.4 %) women had a normal initial scan, but two of them were later readmitted for uterine evacuation. The remaining 271 (35.6 %) women were found to have an abnormal scan: (a) thickened endometrium > 10 mm with hypo- and hyper-echoes and negative Doppler flow considered low suspicion for RPOC was described in 260 cases, of whom 23 (8.8 %) underwent uterine evacuation with placental remnants confirmed in 12/23 (52.2 %), and (b) an echogenic mass with positive Doppler flow considered high suspicion for RPOC was described in 11 cases, all of whom underwent uterine evacuation, with placental remnants confirmed in 9/11 (81.8 %). The number of scans required to detect RPOC in one patient was 33. CONCLUSION: Postpartum ultrasound evaluation may allow for early diagnosis of RPOC in women considered at risk for this condition.

Clinical and sonographic predictors of adnexal torsion in pediatric and adolescent patients.

OBJECTIVE: To investigate the accuracy of torsion diagnosis in the pediatric and adolescent population. METHODS: This retrospective study included 87 patients <18years who presented with acute pelvic pain and were operated for suspected adnexal torsion from January 2009 to September 2016. RESULTS: Adnexal torsion was found in 53 of 87 (60.9%) cases operated for suspected torsion. The rate of accurate torsion diagnosis was significantly higher among pre-menarchal (21/21, 100%) compared with post-menarchal girls (32/66, 48.5%) (p<0.001). Patients with torsion were more likely to report nausea or vomiting (73.6% compared with 32.3%, p<0.001) and had higher rates of peritoneal irritation signs on exam (15.1% compared with 0.0%, p=0.02). On the pre-operative ultrasound, patients with torsion were characterized by higher rates of enlarged ovary showing signs of edema (49.1% compared with 8.8%, p<0.001) and free pelvic fluid (45.3% compared with 17.6%, p<0.001). In post-menarchal girls without adnexal torsion, the leading diagnosis was hemorrhagic corpus luteum cyst (found in 18/33, 78.3%) cases. CONCLUSIONS: Various clinical and ultrasound findings may point to the correct diagnosis of torsion in the pediatric and adolescent population. However, none of the clinical and ultrasound characteristics are sufficient to confirm or disprove the pre-operative diagnosis, and young patients with the clinical suspicion of adnexal torsion should undergo laparoscopy. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Clinical retrospective study.

Does she have adnexal torsion? Prediction of adnexal torsion in reproductive age women.

PURPOSE: The aim of this study was to investigate the association of clinical, laboratory and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion. METHODS: The study included 199 reproductive age women > 16-year-old who underwent urgent laparoscopy for suspected adnexal torsion between January 2008 and December 2014. The association of various parameters with adnexal torsion was analyzed with a multivariate logistic regression analysis and described as odds ratios (OR) ± 95% confidence intervals (CI). RESULTS: Adnexal torsion was surgically diagnosed in 111/199 (55.8%) cases. On the multivariate logistic regression analysis, complaints of nausea/vomiting (OR 4.5, 95% CI 1.8-11.1), peritoneal irritation signs (OR 100.9, 95% CI 4.2-2421.9), elevated white blood cell count > 11,000 cells/mL (OR 3.7, 95% CI 1.3-10.8), presence of free pelvic fluid on ultrasound (OR 34.4, 95% CI 6.7-177.9), ultrasound findings suggestive of ovarian edema (OR 4.2, 95% CI 1.5-11.6), ultrasound findings suggestive of benign cystic teratoma (OR 7.8. 95% CI 1.2-49.4) and location of the ultrasound pathology on the right side (OR 4.7. 95% CI 1.9-11.9) were positively associated with adnexal torsion, while ultrasound findings suggestive of hemorrhagic corpus luteum cyst (OR 0.04, 95% CI 0.008-0.2) were negatively associated with adnexal torsion. By combining these eight parameters, the ROC curve was calculated, yielding an area under the curve of 0.93, 95% CI 0.90-0.97 (p < 0.0001). CONCLUSION: Routine clinical, laboratory and grayscale ultrasound findings may be incorporated into the emergency room workup of women with suspected adnexal torsion. Laparoscopy should be considered in all patients with suspected adnexal torsion.

Hysteroscopic removal of retained products of conception following first trimester medical abortion.

STUDY OBJECTIVE: To investigate the use of operative hysteroscopy instead of traditional curettage in women with retained products of conception (RPOC) following first trimester medical abortion, with the aim of reducing post-operative intrauterine adhesions. DESIGN: Retrospective study. SETTING: Gynecology department in a University affiliated hospital. PATIENTS: All women treated by hysteroscopy for RPOC following first trimester medical abortion using the mifepristone-misoprostol protocol for pregnancy termination or the misoprostol protocol for early missed abortion from January 2013 to August 2016. INTERVENTION: Operative hysteroscopy for removal of RPOC. Post-operative intrauterine adhesions were assessed by diagnostic office hysteroscopy after 6-8 weeks. MEASUREMENTS AND MAIN RESULTS: 50 cases were identified. The mean time from medication administration to the operative hysteroscopy was 1.7 ± 0.7 months. Operative hysteroscopy with blunt use of the resectoscopic loop was used to remove all specimens, and all procedures were completed without intra-operative complications. Two patients (4.0%) were readmitted for fever. Pathology confirmed the presence of RPOC in 45 (90.0%) cases. On follow-up office hysteroscopy, a normal uterine cavity without evidence of intrauterine adhesions was seen in 29/29 (100%) women. CONCLUSION: Hysteroscopy for removal of RPOC following medical abortion is associated with low rates of complications and post-operative intrauterine adhesions.

Isolated Torsion of Accessory Fallopian Tube in a Young Adolescent.

BACKGROUND: Accessory fallopian tube is a rare anatomical variation, which might rarely cause gynecological complications such as infertility, ectopic pregnancy, cystic swelling, and pyosalpinx. It is usually diagnosed by surgeons during diagnostic laparoscopy for other purposes. We present a rare case of isolated accessory tube torsion in a young adolescent. CASE: A 16-year-old virgin teen presented with a 24-hour history of aggravating right lower-quadrant abdominal pain and nausea without vomiting or fever. On examination she had right lower quadrant abdominal tenderness with no peritoneal signs. On pelvic ultrasound a right corpus luteum cyst was suspected, but right adnexal torsion could not be ruled out. On laparoscopy, torsion of the right accessory tube was diagnosed. Because of its ischemic and bluish appearance it was removed. The postoperative course was uneventful. Pathology confirmed the diagnosis. SUMMARY AND CONCLUSION: Torsion of an accessory fallopian tube is rare. An English literature search showed that the current case is the third reported overall and the first in a young adolescent. Because of the rarity of this congenital variation, and the low suspicion index for its existence, the diagnosis of accessory tube is often missed. Preventive removal of such findings should be considered but weighed against its possible surgical complications.

Primary Ovarian Ectopic Pregnancy: Still a Medical Challenge.

OBJECTIVE: To investigate the clinical presentation of women with primary ovarian pregnancy diagnosed in recent years and to compare it to tubal pregnancy. STUDY DESIGN: Seven women treated for primary ovarian pregnancy from 2002-2013 were retrospectively identified and compared to 42 women with tubal pregnancies (involving either tubal rupture or tubal abortion) operated on during the same period. In the ovarian pregnancy group the pathology examination confirmed primary ovarian pregnancy according to the Spiegelberg criteria. RESULTS: Seven women underwent surgery for primary ovarian pregnancy during the study period. Five women presented with hemodynamic shock. A ruptured ovarian pregnancy was identified in all cases. Wedge resection was performed by laparotomy in 1 case and by laparoscopy in 6 cases. The mean estimated blood loss was significantly higher in those women with ovarian versus tubal pregnancy (1057.1 ± 472.1 mL vs. 250.2 ± 241.5 mL, respectively, p<0.001). Moreover, a statistically significant difference was found when we compared postoperative hospitalization days (2 ± 0.6 vs. 1.3 ± 0.7, respectively; p=0.01) in the ovarian pregnancy group as compared with the tubal pregnancy group. CONCLUSION: Primary ovarian ectopic pregnancy is still a major challenge for early diagnosis and treatment; it is associated with rupture and massive intraabdominal bleeding.

High risk of recurrent torsion in premenarchal girls with torsion of normal adnexa.

OBJECTIVE: To compare adnexal torsion characteristics and torsion recurrence rates in a pre- and postmenarchal pediatric and adolescent population. DESIGN: Retrospective cohort study. SETTING: University-affiliated medical center. PATIENT(S): Females <18 years old with surgically diagnosed adnexal torsion. INTERVENTION(S): Adnexal detorsion, cystectomy, salpingectomy, or salpingo-oophorectomy by laparoscopy or laparotomy. Oophoropexy using the utero-ovarian ligament plication technique was performed in cases of recurrent torsion of normal adnexa. MAIN OUTCOME MEASURE(S): The clinical presentation, laboratory and ultrasound characteristics, surgical findings, surgical procedures, pathologic diagnosis, and torsion recurrence rates were analyzed and compared between pre- and postmenarchal patients. RESULT(S): Twenty premenarchal and 24 postmenarchal patients were identified. The clinical presentation, laboratory findings, and ultrasound characteristics were similar between the two groups, except for a higher prevalence of paraovarian cysts on preoperative ultrasound in the postmenarchal compared with in the premenarchal group (20.8% vs. 0%). For the whole cohort, torsion of normal adnexa constituted 25.0% (11/44) of cases, while torsion of "pathologic" adnexa constituted 75.0% (33/44) of torsion cases. Torsion recurrence was significantly more common among girls whose first torsion episode occurred in the premenarchal period compared with in postmenarche (35% vs. 4.2%). On multivariate logistic regression analysis, torsion recurrence was significantly associated with premenarchal status (odds ratio [OR] = 12.7; 95% confidence interval [CI], 1.1-152.0) and with torsion involving normal adnexa (OR = 19.1; 95% CI, 2.3-154.5). CONCLUSION(S): Recurrent torsion is common in patients whose first torsion episode occurred in the premenarchal period and involved otherwise normal adnexa. Ovarian fixation procedures may be considered in patients at risk for torsion recurrence.

Similar But Different: A Comparison of Adnexal Torsion in Pediatric, Adolescent, and Pregnant and Reproductive-Age Women.

BACKGROUND: We sought to investigate and compare the clinical presentation, ultrasound findings, surgical characteristics, and causes of adnexal torsion among three groups: pediatric and adolescent population, reproductive-age women, and pregnant women. MATERIAL AND METHODS: Two hundred twenty-seven surgically confirmed episodes of adnexal torsion in 199 patients treated in our department from January 2008 to December 2014 were retrospectively analyzed. RESULTS: Abdominal pain duration of >24 hours before emergency room presentation was more common in pediatric and adolescent patients compared with reproductive-age and pregnant women (42.3% vs. 28.4% and 15.5%, respectively, p = 0.04). However, there was no difference between the groups in the time interval from their emergency room admission to surgery. Torsion of "normal adnexa" occurred in 11/44 (25.0%) of pediatric and adolescent patients, 30/99 (30.3%) of reproductive-age patients, and 12/56 (21.4%) of pregnant patients, while torsion involving multicystic ovaries occurred in 0%, 4%, and 32.1%, respectively, torsion involving paraovarian cysts occurred in 20.5%, 14.1%, and 1.8%, respectively, and torsion involving benign dermoid cysts occurred in 4.5%, 15.2%, and 5.4%, respectively (p < 0.001). Torsion involving supposedly functional ovarian cysts occurred in 45.5%, 34.3%, and 69.6%, respectively (p < 0.001). The torsion recurrence rates were 18.2% in the pediatric subjects, 19.2% in reproductive-age women, and 10.7% in pregnant women (p = 0.3). CONCLUSIONS: The presentation of adnexal torsion is similar in pediatric and reproductive-age and pregnant women, although the underlying adnexal pathology may be different. Functional ovarian cysts cause the majority of torsion cases in pregnant women. Recurrence of torsion may occur in any age group.

Infertility Following Retained Products of Conception: Does the Timing of Surgical Intervention Matter?

BACKGROUND: Despite the large volume of evidence on the management of retained products of conception (RPOC), there are virtually no data regarding the optimal time frame of surgical intervention in case of RPOC. OBJECTIVES: To examine whether the time interval between spontaneous vaginal delivery or pregnancy termination and the uterine evacuation due to pathologically confirmed RPOC influences the reproductive outcome. METHODS: We retrospectively reviewed all the records of women who were admitted to our department due to pathologically confirmed RPOC following either spontaneous vaginal delivery or pregnancy termination between January 2000 and December 2010. Based on the median time from delivery or pregnancy termination until the operative intervention in the study group, patients were stratified into two groups: early intervention (< 3 weeks) and late intervention (> 3 weeks). Reproductive outcomes were compared between the two study groups. RESULTS: Reproductive outcomes were analyzed in 172 patients with pathologically confirmed RPOC. Of them, 95 (55.2%) were included in the early intervention group and 77 (44.8%) in the late intervention group. There were no significant differences in the conception rate, mean time to conception, and the occurrence rate of a new infertility problem in women with early surgical intervention compared to those with late surgical intervention (P > 0.05). Furthermore, there was no significant difference between the groups in the pregnancy outcomes following RPOC. CONCLUSIONS: Early surgical intervention in women with pathologically confirmed RPOC following spontaneous vaginal delivery or pregnancy termination yields the same reproductive outcomes as late surgical intervention.