Medical management of early pregnancy failure with misoprostol with rupture of the cesarean section scar pregnancy.

PURPOSE: To report a case of ruptured uterus in the first trimester with the use of misoprostol for early pregnancy tailure in a woman with unrecognized cesarean section scar pregnancy. CASE: A 27-year-old woman, gravida 5 para 3+1, presented with abdominal pain and vaginal bleeding. Transvaginal ultrasonography revealed a fetus without fetal heart activity at nine weeks gestation, making the diagnosis of early pregnancy failure. Her previous deliveries were by cesarean section. She was managed medically with misoprostol. Seven hours after misoprostol administration, she developed sudden onset of severe abdominal pain. Repeat transvaginal ultrasonography diagnosed cesarean section scar pregnancy. Laparotomy revealed hemoperitoneum with rupture of cesarean section scar pregnancy. Subtotal hysterectomy was performed. CONCLUSIONS: Failure to recognize cesarean section scar pregnancy can result in a ruptured uterus in the first trimester with the use of misoprostol for early pregnancy failure. Increased awareness of the unexpected consequences of cesarean section is of paramount importance.

Peripartum hysterectomy: 10-year experience in two manitoba tertiary centers.

BACKGROUND: The aim of the study was to review the incidence, associated risk factors, indications and complications of peripartum hysterectomy in the two teaching hospitals of the University of Manitoba, Canada. PATIENTS AND METHODS: We conducted a retrospective study of all cases of peripartum hysterectomy that occurred over a 10-year period at the Health Sciences Centre (HSC), and over a five-year period at St. Boniface General Hospital (SBGH), the two tertiary centers in Winnipeg, Manitoba. RESULTS: Twenty-five peripartum hysterectomies were identified among 59,839 deliveries at both HSC and SBGH, for an overall incidence of 0.4/1000 births. Twenty-three hysterectomies (92%) were performed as emergency procedures, 19 (76%) followed a cesarean section (relative risk = 15), and 15 patients had single or multiple prior cesarean section scars (relative risk = 14.2). The indications for hysterectomy were: hemorrhage due to placenta/accreta (n=9); uterine atony (n=6); uterine rupture (n=5); retroperitoneal hematoma (n=2); and cervical laceration (n=1). Two cases were performed electively for cervical and ovarian cancer, respectively. Twenty-three women (92%) required blood transfusion, five (20%) had coagulopathy, four (16%) had bladder injuries, and three (12%) required salpingo-oophorectomy for uncontrolled adnexal bleeding. CONCLUSION: Our reported incidence for peripartum hysterectomy is lower than that reported elsewhere in the recent literature, while the risk factors for hysterectomy were similar to those reported. Although the maternal mortality was nil in this study, morbidity was high.

Laparoscopic Use of Argon Beam Coagulator in the Management of Endometriosis

Fifty-five patients with endometriosis in whom argon beam coagulation was used through the laparoscope for coagulation of endometrial lesions, lysis of pelvic adhesions, uterosacral nerve ablation (LUNA) and presacral neurectomy (PSN) were evaluated retrospectively. Thirty patients (54%) had pelvic pain, and 25 patients (46%) presented with pelvic pain and/or infertility. Postoperatively, 29 (72.5%) women showed improvement of pain, 6 (15%) had no change of pain, and in 5 (12.5%) the pain became worse. Seven patients were able to conceive after longstanding infertility, for an early crude pregnancy rate of 28%. Laparoscopic use of argon beam coagulator in the treatment of endometriosis for both pain management and infertility is as effective as other electrosurgical or laser techniques.