Tubal Ectopic Pregnancy with Undetectable Initial Serum ß-Human Chorionic Gonadotropin Level.

We present a case of a tubal ectopic pregnancy (EP) in a patient with an initially undetectable serum ß-human chorionic gonadotropin (ß-hCG) level. A 33-year-old woman in a same-sex relationship underwent timed donor intrauterine insemination. Her serum ß-hCG level was <5 mIU/mL 14 days after the intrauterine insemination. She reported menstrual bleeding 3 days after her negative pregnancy test and returned to the office 10 days later to begin a new treatment cycle. Her serum levels of estradiol, progesterone, and ß-hCG were 119 pg/mL, 6.1 ng/mL and 1157 mIU/mL, respectively. Transvaginal ultrasonography did not show an intrauterine pregnancy. Her ß-hCG level increased to 1420 mIU/mL the next day. She was diagnosed with a pregnancy of unknown location and treated with methotrexate. Her ß-hCG levels continued to increase despite 3 methotrexate doses, necessitating laparoscopy. The diagnostic laparoscopy demonstrated approximately 100 mL of hemoperitoneum in the posterior cul-de-sac with an intact right fallopian tube that was dilated at its distal end by the EP. A total right salpingectomy was performed. Her ß-hCG level was <5 mIU/mL 3 weeks later. The current case supports that although rare, an undetectable serum ß-hCG level does not completely rule out the diagnosis of an EP.

Rotational thromboelastometry (ROTEM) parameters in dogs with haemoperitoneum and their associations with clinical and laboratory signs.

INTRODUCTION: Rotational thromboelastometry (ROTEM) is a viscoelastic coagulation test that allows the evaluation of haemostasis from clot formation to clot dissolution. The aim of this retrospective study was to describe the changes in haemostasis using ROTEM parameters in dogs presenting with spontaneous or traumatic haemoperitoneum and to evaluate any associations between clinical and laboratory parameters at presentation with the ROTEM. We hypothesized that the dogs would show signs of hypocoagulability and hyperfibrinolysis and that these changes would correlate with the degree of hypoperfusion. Clinical records were searched for a period of 5 years for dogs presenting with a haemoperitoneum und for whom a -ROTEM analysis at presentation was carried out. Forty dogs were identified, and various clinical and laboratory parameter (heart rate, blood pressure, blood glucose, lactate, serum albumin concentration, PCV (venous and abdominal), ionized calcium, pH and base excess) were retrieved. The following ROTEM parameters were analysed: extrinsic clotting time (ExTEM CT), clot formation time (ExTEM CFT), clot firmness (ExTEM MCF) and maximum lysis (ExTEM ML), as well as fibrinogen (FibTEM) CT and MCF. Compared to institutional reference intervals, dogs with haemoabdomen showed prolongation of ExTEM and FibTEM CT, ExTEM CFT and 50% were hypocoagulable and 62% thrombocytopenic. No hyperfibrinolysis could be detected. Multiple linear regression models showed an association between decreased base excess, trauma and ROTEM signs for hypocoagulability. Furthermore, age was associated with a stronger fibrin clot. In conclusion, 50% of the dogs presented hypocoagulable and changes in ROTEM parameters are similar to those seen with consumption coagulopathy. Base excess and trauma were associated with hypocoagulability, while increasing age was associated with a stronger fibrin clot.

INTRODUCTION: La thromboélastométrie rotationnelle (ROTEM) est un test de coagulation viscoélastique qui permet d'évaluer l'hémostase depuis la formation du caillot jusqu'à sa dissolution. Le but de cette étude rétrospective était de décrire les changements de l'hémostase à l'aide des paramètres ROTEM chez des chiens présentant un hémopéritoine spontané ou traumatique et d'évaluer d'éventuelles association entre les paramètres cliniques et de laboratoire lors de la présentation avec le ROTEM. Nous avons émis l'hypothèse que les chiens montreraient des signes d'hypocoagulabilité et d'hyperfibrinolyse et que ces changements seraient en corrélation avec le degré d'hypoperfusion. Les dossiers cliniques ont été recherchés surune période de 5 ans pour les chiens présentant un hémopéritoine et pour lesquels une analyse ROTEM à la présentation avait été effectuée. Quarante chiens ont été identifiés et divers paramètres cliniques et de laboratoire (fréquence cardiaque, tension artérielle, glycémie, lactate, concentration d'albumine sérique, PCV (veineux et abdominal), calcium ionisé, pH et excès basique) ont été relevés. Les paramètres ­ROTEM suivants ont été analysés: temps de coagulation extrinsèque (ExTEM CT), temps de formation de caillot (ExTEM CFT), fermeté du caillot (ExTEM MCF) et lyse maximale (ExTEM ML), ainsi que fibrinogène ­(FibTEM) CT et MCF. Par rapport aux intervalles de référence admis, les chiens avec hémoabdomen ont montré une prolongation d'ExTEM et FibTEM CT, ExTEM CFT, 50% étaient hypocoagulables et 62% thrombocytopéniques. Aucune hyperfibrinolyse n'a pu être détectée. Plusieurs modèles de régression linéaire ont montré une association entre une diminution de l'excès basique, des traumatismes et des signes ROTEM d'hypocoagulabilité. De plus, l'âge était associé à un caillot de fibrine plus fort. En conclusion, 50% des chiens présentaient une hypocoagulabilité et les changements dans les paramètres ROTEM sont similaires à ceux observés lors de coagulopathie de consommation. Un excès basique et un traumatisme étaient associés à une hypocoagulabilité, tandis qu'une augmentation de l'âge était associée à un caillot de fibrine plus fort.

Fibrinolysis in trauma patients: wide variability demonstrated by the Lysis Timer.

Hyperfibrinolysis contributes to the pathophysiology of trauma-induced coagulopathy. At present, systematic administration of tranexamic acid (TXA) is recommended in all patients in the early phase of trauma. However, there is some debate regarding whether TXA is beneficial in all trauma patients. A rapid and accurate tool to diagnose hyperfibrinolysis may be useful for tailoring TXA treatment. We conducted a proof-of-concept study of consecutive adult trauma patients. A first blood sample was obtained at the time of pre-hospital care (T1). Patients received 1 g of TXA after T1. A second sample was obtained on arrival at the emergency unit (T2). We examined coagulation, fibrin and fibrinogen formation and degradation. Fibrinolysis was assessed by determining tissue plasminogen activator (t-PA) antigen and plasminogen activator inhibitor 1 (PAI-1) activity and global fibrinolysis capacity assay using a device developed by Hyphen BioMed: the Lysis Timer (GFC/LT). The study population consisted of 20 patients (42 ± 21 years, index of severity score 32 ± 21). Both coagulation and fibrinolysis were altered at T1. GFC/LT values exhibited hyperfibrinolysis only in five patients. Principal component analysis carried out at T1 showed two main axes of alteration. The major axis was related to coagulation, altered in all patients, while the second axis was related to fibrinolysis. GFC/LT was mainly influenced by PAI-1 activity while fibrin monomers were related to the severity of trauma. At T2, GFC/LT exhibited the marked effect of TXA on clot lysis time. In conclusion, GFC/LT demonstrated huge variation in the fibrinolytic response to trauma.

Management and outcome of hepatocellular adenoma with massive bleeding at presentation.

AIM: To evaluate outcome of acute management and risk of rebleeding in patients with massive hemorrhage due to hepatocellular adenoma (HCA). METHODS: This retrospective cohort study included all consecutive patients who presented to our hospital with massive hemorrhage (grade II or III) due to ruptured HCA and were admitted for observation and/or intervention between 1999-2016. The diagnosis of HCA was based on radiological findings from contrast-enhanced magnetic resonance imaging (MRI) or pathological findings from biopsy or resection of the HCA. Hemorrhage was diagnosed based on findings from computed tomography or MRI. Medical records were reviewed for demographic features, clinical presentation, tumor features, initial and subsequent management, short- and long-term complications and patient and lesion follow-up. RESULTS: All patients were female (n = 23). Treatment in the acute phase consisted of embolization (n = 9, 39.1%), conservative therapy (n = 13, 56.5%), and other intervention (n = 1, 4.3%). Median hemoglobin level decreased significantly more on days 0-3 in the intervention group than in the patients initially treated conservatively (0.9 mmol/L vs 2.4 mmol/L respectively, P = 0.006). In total, 4 patients suffered severe short-term complications, which included hypovolemic shock, acute liver failure and abscess formation. After a median follow-up of 36 mo, tumor regression in non-surgically treated patients occurred with a median reduction of 76 mm down to 25 mm. Four patients underwent secondary (elective) treatment (i.e., tumor resection) to address HCA size of > 5 cm and/or desire for future pregnancy. One case of rebleeding was documented (4.3%). None of the patients experienced long-term complication (mean follow-up time: 36 mo). CONCLUSION: With a 4.3% risk of rebleeding, secondary (elective) treatment of HCA after massive hemorrhage may only be considered in patients with persistent HCA > 5 cm.

Laparoscopic Management of Abdominal Pregnancy.

OBJECTIVE: To illustrate the laparoscopic surgical management of a particular localization of extrauterine pregnancy misdiagnosed until 12 weeks gestational age, complicated by hemoperitoneum and abortion. DESIGN: Canadian Task Force III on the Periodic Health Examination's Levels of Evidence. SETTING: The prevalence of ectopic pregnancy among women presenting to an emergency department with first trimester bleeding, pain, or both ranges from 1% to 16% [1]. The most common localization of ectopic pregnancy is the fallopian tubes, whereas abdominal pregnancy accounts for at least 1% of extrauterine pregnancies. The reported incidence of abdominal pregnancy ranges from 1:10 000 to 1:30 000 pregnancies [2]. Abdominal pregnancy can be localized in the pelvic cul-de-sac, broad ligament, bowel, or pelvic sidewall. This rare type of ectopic pregnancy is often misdiagnosed until later in pregnancy, evolving in hemoperitoneum, abortion, embolism, or rarely, in diagnosed cases, live birth by cesarean section. In the literature, it is recommended that the placenta be left in situ in cases of abdominal pregnancy to avoid hemorrhage and organ injury, even though this approach may be associated with a higher rate of postoperative complications, such as infection, secondary bleeding, and cancer transformation [3]. We present a case of abdominal pregnancy in which the gestational sac was implanted in the broad ligament and resulted in hemoperitoneum at 12 weeks gestational age. INTERVENTION: In August 2010, a 35-year-old woman, gravida 3 para 1, presented at the Di Meglio ultrasound diagnostic center in Naples for a noninvasive prenatal ultrasound (bi-test) to confirm gestational age in what to that point had been considered a normal pregnancy at 12 weeks gestation. Ultrasound revealed an ectopic abdominal pregnancy with a live fetus located in the left parauterine side. A suspicious fluid level in the pouch Douglas was also detected, and so the woman was advised to go to an obstetric hospital for a medical evaluation of the clinical situation (starting hemoperitoneum). Later that same day, the woman presented at the Villa dei Platani Hospital in Avellino, where ultrasound confirmed increased fluid in the pouch of Douglas, along with initial signs of hemoperitoneum and loss of the fetal heartbeat. The woman was immediately transferred to the Malzoni Center for Advanced Endoscopic Gynecological Surgery in Avellino, where she underwent operative laparoscopy for removal of the abdominal pregnancy (surgeon, M.M.). Informed consent for the laparoscopic surgery was provided by the patient in accordance with local regulations. The patient also provided informed consent for the use of images and a video of the procedure. Institutional Review Board approval was not required. The procedure involved laparoscopic hemoperitoneum drainage (at least 500 mL of blood), left adnexectomy after transperitoneal identification of the left uretheral pathway, and complete removal of left broad ligament pregnancy abortion with consensual removal of the ectopic placenta. CONCLUSION: The laparoscopic management of abdominal pregnancy and hemoperitoneum resulting from rupture of the gestational chamber and abortion was optimal. With this minimally invasive technique, it was possible to drain the hemoperitoneum completely and then proceed to total removal of the gestational chamber and the fetus. Thanks to the magnification of the image by laparoscopy, it was also possible to completely remove the placenta and the cotyledons from the peritoneal surface, thereby avoiding possible postoperative bleeding, infection, and sepsis resulting from retention of incomplete removal of the placenta. On the first postoperative day, the patient was in excellent clinical condition, with a marked reduction in circulating ß-human chorionic gonadotropin. She was discharged on the second postoperative day and currently is in good health.

Hemoperitoneo por rotura espontánea de bazo no patológico en paciente fumador, simulando una perforación de ulcus duodenal: a propósito de un caso / Hemoperitoneum secondary to an spontaneous rupture of the spleen mimmicking a duodenal perforated ulcera: a case report

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Hemoperitoneo secundario a tumor miofibroblástico inflamatorio perforado. Presentación de una complicación inusual / Hemoperitoneum secondary to perforated inflammatory myofibroblastic tumor: a case report of an unusual complication

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Serum 25-hydroxyvitamin D concentrations in dogs - correlation with health and cancer risk.

25-hydroxyvitamin D (25(OH)D) is important in bone health as well as many diseases including cancer. Supplementation may increase responsiveness of cancer cells to chemotherapy. Serum 25(OH)D, intact parathyroid hormone (iPTH) and canine C-reactive protein (c-CRP) were measured in healthy dogs and dogs with haemoabdomen. Regression analysis determined optimal 25(OH)D concentrations. In healthy dogs (n = 282), mean iPTH concentrations correlated inversely (r(2) = 0.88, P < 0.001) to 25(OH)D concentrations. Variation in both iPTH and c-CRP plateaued at 25(OH)D concentrations of 100-120 ng mL(-1) . Haemoabdomen dogs (n = 63, 43 malignant and 20 benign) had 25(OH)D concentrations ranging from 19.4 to >150 ng mL(-1) . Relative risk of cancer increased with decreasing 25(OH)D concentrations [RR = 3.9 for 25(OH)D below 40 ng mL(-1) (P = 0.0001)]. Serum 25(OH)D concentrations in dogs vary widely, and are influenced by dietary VitD content. Serum vitD measurement can identify dogs for which supplementation may improve health and response to cancer therapy.

Assessment of the relationships among coagulopathy, hyperfibrinolysis, plasma lactate, and protein C in dogs with spontaneous hemoperitoneum.

OBJECTIVE: To relate coagulation and fibrinolysis derangements to shock severity as reflected by plasma lactate concentrations in dogs with spontaneous hemoperitoneum (SHP) and determine the impact on transfusions. DESIGN: Prospective, observational, case-control study. SETTING: Three veterinary teaching hospitals. ANIMALS: Twenty-eight client-owned dogs with SHP and 28 breed- and age-matched control dogs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Blood samples for platelet counts, coagulation, and anticoagulant assays (prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin, and protein C, thromboelastography [TEG]), fibrinolysis testing (d-dimer and TEG lysis parameters with and without the addition of 50 U/mL of tissue plasminogen activator [TEG LY30 measured with the addition of 50 U/mL of tPA to the blood sample, LY3050 and TEG LY60 measured with the addition of 50 U/mL of tPA to the blood sample, LY6050 ; LY30 and LY60]), and plasma lactate as an indicator of severity of shock were collected from SHP dogs at the time of diagnosis. SHP dogs were hypocoagulable (prolonged prothrombin time and activated partial thromboplastin time, decreased TEG maximum amplitude) and hyperfibrinolytic (increased LY3050 and TEG LY6050 ) compared to controls. The severity of hypocoagulability was related to protein C activity, while the severity of hyperfibrinolysis was related to plasma lactate concentration. Among the 18 dogs discharged from the hospital, LY3050 was significantly associated with the dose of fresh frozen plasma administered, but none of the parameters were associated with the dose of red blood cells administered. CONCLUSIONS: Dogs with SHP have evidence of hypocoagulability, protein C deficiency, and hyperfibrinolysis. Parameters of hyperfibrinolysis were related to plasma lactate concentrations and volume of plasma transfused during hospitalization. These derangements resemble those found in people with acute coagulopathy of trauma and shock, and activation of protein C may be a common feature to both syndromes.

Hemocholecyst: a rare cause of acute abdomen

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Prediction of location of gestational sac for pregnancy of unknown location at first sight during exploratory surgery using the ratio of hCG in haemoperitoneum and venous serum.

OBJECTIVE: To evaluate a practical method to predict the location of gestational sacs for pregnancy of unknown location (PUL) during exploratory surgery. STUDY DESIGN: Sixty-nine cases of PUL with a positive pregnancy test and haemoperitoneum but unknown location of the gestational sac at first sight on exploratory surgery were analysed at the Department of Obstetrics and Gynaecology, Shanghai Jiaotong University. The level of hCG in the haemoperitoneum and venous serum were measured, and the ratio of hCG in haemoperitoneum and venous serum (Rp/v-hCG) was calculated. Rp/v-hCG<1.0 was taken to suggest an intrauterine gestational sac, and Rp/v-hCG>1.0 was taken to suggest an abdominal gestational sac. The sensitivity and specificity of Rp/v-hCG for predicting the location of the gestational sac were evaluated prospectively. RESULTS: Among 69 cases of PUL, 17 cases (17/69) were ultimately diagnosed as abdominal gestational sacs before 9 weeks of gestation, and 52 cases (52/69) were ultimately diagnosed as intrauterine gestational sacs. The diagnostic sensitivity and specificity of Rp/v-hCG at the time of exploratory surgery for predicting the location of the gestational sac were 94.1% and 100%, respectively (kappa=0.96; P=0.039). The rate of missed diagnosis was 5.9%. The location of the gestational sac was determined during the initial exploratory procedure for 15 cases (15/17) with an abdominal gestational sac (1 case of splenic pregnancy was diagnosed during secondary surgery) and 37 cases (37/52) with an intrauterine gestational sac. With the exception of gestational sacs located in the pouch of Douglas (52.9%, 9/17), the gestational sacs (47.1%, 8/17) located in the other places were difficult to find. CONCLUSIONS: Rp/v-hCG should be considered when exploratory surgery reveals no visible gestational sacs at first sight. If Rp/v-hCG is >1.0, more careful pelvic or abdominal exploration is required, rather than dilation and curettage, to locate abdominal gestational sacs.

Is serum human chorionic gonadotrophin follow-up necessary after suspected spillage of trophoblast at the time of laparoscopic surgery for ectopic pregnancy?

BACKGROUND: Persistent trophoblast is a recognised complication of salpingostomy for the treatment of ectopic pregnancy, with reported rates of 3-20%; hence, women are advised to have serum human chorionic gonadotrophin (hCG) levels monitored post-operatively. Although much less common, there are also reports of disseminated trophoblastic peritoneal implants after laparoscopic salpingectomy. The aim of this study was to assess whether monitoring of post-operative serum hCG levels is necessary in women undergoing salpingectomy, where intra-operative spillage of trophoblast is thought to have occurred. METHODS: This was a retrospective study of women who underwent serum hCG follow-up after salpingectomy. Serum hCG levels were monitored if: (1) the ectopic pregnancy was found to be ruptured; (2) there was a significant haemoperitoneum (>500 ml); (3) there was thought to be spillage of trophoblast at the time of salpingectomy or (4) a tubal miscarriage was diagnosed. Serum hCG levels were taken at days 1-2, days 3-4, days 6-8 or days 13-15 post-surgery. Women were followed up until the serum hCG level was <15 IU/l. Persistent trophoblast was defined as a failure of the serum hCG level to decrease spontaneously after surgery. RESULTS: 105 women underwent serum hCG follow-up after a laparoscopy for a tubal ectopic pregnancy. Of these women, 92 had a laparoscopic salpingectomy and 13 were diagnosed with a tubal miscarriage at the time of laparoscopy. In all women the serum hCG decreased spontaneously. CONCLUSION: It does not appear necessary to routinely monitor serum hCG levels post-operatively in women diagnosed with tubal miscarriages, in those undergoing salpingectomy for a ruptured ectopic pregnancy or in cases of salpingectomy, where there is thought to be spillage of trophoblast.

Hepatic tear as an elusive cause of hemoperitoneum complicating cardiac surgery.

We report an unusual source of intra-operative bleeding in a patient undergoing cardiosurgical reoperation. After sternotomy, hematocrit dropped significantly. Only intra-thoracic bleeding from adhesions was considered to be responsible for the anemia. During reperfusion, abdominal wall was distended with a bluish bulge in the right hemidiaphragm. Immediate laparotomy revealed bleeding from a tear in the right hepatic lobe without any diaphragm injury. The tear was likely caused by blunt trauma from an oscillating saw. We emphasize cautious use of an oscillating saw in patients with hepatic congestion undergoing a repeat sternotomy. We propose that lifting the sternum in redo procedures might prevent the hepatic tear.

Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam.

The multiple-view focused assessment with sonography for trauma (FAST) exam is an integral tool in the assessment of blunt abdominal trauma. A prospective observational study was performed to compute the average minimum volume of detectable intraperitoneal fluid with the pelvic views of the FAST exam. All adult patients from October 1999 to May 2001, who presented to the ED with blunt abdominal trauma and underwent a clinically indicated diagnostic peritoneal lavage (DPL), were candidates for admission to the pelvic ultrasound study. In the supine position, patients were administered lavage fluid in 100 cc increments until the examiner detected the fluid on ultrasound. An independent reviewer also examined the hard-copy ultrasound images for fluid detection. Patients were excluded if they had (1) a positive DPL for hemoperitoneum (defined as 10 cc of gross blood or >100,000 red blood cells/mL), (2) a positive initial ultrasound for free fluid, or (3) lacked sufficient hard-copy ultrasound images. The mean minimal volume of fluid needed for pelvic ultrasound detection by the examiner and reviewer was 157 and 129 cc (n = 7), respectively. The median quantity of fluid for ultrasound detection by both the examiner and reviewer was 100 cc. The pelvic views of the FAST exam identified a significantly smaller quantity of intraperitoneal fluid than previous studies of the right upper quadrant single-view exam.

Increased fibrinolytic activity and body cavity coagula.

When a large volume of coagulum remains in the body cavity after trauma or surgery, secondary fibrinolysis occurs, which disturbs the hemostatic balance and results in rebleeding. To better understand this condition, we conducted a clinical study on patients with and without coagula and an experimental study on fibrinolytic activity in a rat model. The results of the clinical study showed that when coagula existed in the body cavity, the blood levels of the fibrin degradation products D-dimer and fibrinopeptide Bbeta15-42 remained high compared with when subjects were under similar stress but without the presence of coagula. In the experimental studies, fibrinolytic activity of the omentum, measured by the fibrin plate method, was higher in rats with hemoperitoneum. This suggests that increased fibrinolytic activity may lead to rebleeding from the area of transient hemostasis when coagulum is present in the body cavity.

[Duodenal hematoma, acute pancreatitis, and hemoperitoneum after endoscopic hemostasis for duodenal ulcer]. / Hématome duodénal, pancréatite aiguë et hémopéritoine après hémostase endoscopique d'un ulcère duodénal.

Therapeutic endoscopy is followed by complications in less than 5% of cases. We report a case of an intramural duodenal hematoma after local endoscopic injection of 28 mL of adrenaline 1/10,000 for a bleeding duodenal peptic ulcer. This hematoma was associated with acute pancreatitis and was revealed by a hemoperitoneum.