Laparoscopic management of a primary posterior cul-de-sac abdominal ectopic pregnancy.

OBJECTIVE: To report a case of laparoscopic management of a primary posterior cul-de-sac abdominal ectopic pregnancy (AEP). DESIGN: Video article. SETTING: Academic medical center. PATIENT(S): A 40-year-old G5P3013 woman at approximately 7 weeks of pregnancy was referred to our emergency department because of abnormally rising ß-human chorionic gonadotropin levels. Transvaginal ultrasonography revealed a cystic structure measuring 2.8 × 1.6 ×1.9 cm in the posterior cul-de-sac distinct from the cervix. The mass was noted to have peripheral hypervascularity and a thickened wall. A moderate amount of complex free fluid was noted adjacent to the mass. The patient's baseline ß-human chorionic gonadotropin level and hematocrit were 6,810.7 mIU/mL and 42.4%, respectively. INTERVENTION(S): Laparoscopy for suspected AEP. MAIN OUTCOME MEASURE(S): Laparoscopic excision of a primary AEP. RESULT(S): Diagnostic laparoscopy revealed a normal uterus, normal right ovary, normal left ovary with a corpus luteal cyst, and normal bilateral fallopian tubes without dilatation or hemorrhage. The AEP was noted in the right posterior cul-de-sac and was excised from the underlying peritoneum. The left lateral aspect of the AEP extended into the posterior vaginal wall. The patient was admitted for overnight observation, and her postoperative hematocrit was 35.1%. CONCLUSION(S): AEPs are extremely rare and account for 1% of all ectopic pregnancies. Approximately 90% of AEPs require surgical management. Historically, AEPs were treated with laparotomy because of the high risk of hemorrhage and hemodynamic instability. However, as exemplified by the current case, laparoscopy is a safe and feasible option for surgical management of AEPs.

Combination uterine artery embolization and hysteroscopic resection for a symptomatic uterine leiomyoma: A collaborative single-session approach for better patient care.

Uterine artery embolization (UAE) for symptomatic uterine fibroids is accompanied by transcervical fibroid expulsion in 3-15% of cases. It can be a source of significant patient distress, may require reintervention for removal, and is the most common reason for hospital readmission following UAE. Conversely, the success of hysteroscopic resection decreases with increasing fibroid size while the risk of complications increases. Because certain fibroid features identifiable on preoperative imaging predict need for eventual hysteroscopic resection, it is possible to prospectively identify such patients and employ an alternative management strategy. We present such an approach, illustrated in the case of a woman with a pedunculated broad-based uterine fibroid successfully managed via combination UAE and immediate hysteroscopic resection.

Percutaneous drainage of an infected endometrioma.

Endometrioma superinfection is uncommon and poorly described in the literature. This rarity has precluded agreement on optimal management, with most authors treating these lesions as endometriomas rather than abscesses and thus recommending laparoscopic or open cystectomy or oophorectomy. We present a minimally-invasive alternative, illustrated in the case of an infected endometrioma which was successfully managed via image-guided percutaneous drainage.

Clinical and laboratory issues associated with persistent low-level elevations of hCG in a female of childbearing age.

Persistent low-level elevations of serum concentrations of hCG in a non-pregnant female of childbearing age were investigated by a number of laboratory techniques including heterophile blocking reagents, polyethylene glycol precipitation, serial dilutions and hCG measurements on several different instrument/reagent systems. The results of these studies indicated that this patient had immunoreactive hCG in her serum that was not the intact hCG molecule but primarily the free ß-hCG subunit. Differential diagnoses are discussed along with recommendation for continued surveillance of serum hCG concentrations.