Is it necessary to operate on all women with an acute abdomen following medical treatment of tubal ectopic pregnancy?

The main objective of this retrospective study is to evaluate the question of whether it is necessary to perform surgery for patients who develop an acute abdomen after methotrexate administration in cases of tubal ectopic pregnancy. A total of 26 women with tubal ectopic pregnancy who required emergency surgical evaluation after a single dose of methotrexate treatment were included. The surgical findings were tubal abortion (10 cases, 38.4%); tubal rupture (12 cases, 46.2%) and tubal haematoma (4 cases, 15.4%). The average time for initiation of severe abdominal pain following single dose methotrexate treatment was 6.12 +/- 2.10 days (range, 2-10). The most common site of implantation was isthmus (50.0%) and 38.5% (five patients) of the patients had tubal abortion from this part of the tube, while 46.1% of women (six patients) with isthmic localisation had a tubal rupture. Following medical treatment of ectopic pregnancy, surgery may be an option in the presence of symptoms/signs of acute abdomen (in the presence or absence of haemodynamic instability) and free pelvic fluid on sonography for only patients with isthmic tubal ectopic pregnancy, or if the isthmic localisation of tubal ectopic pregnancy is suspected on sonography.

Placenta previa percreta with urinary bladder and ureter invasion.

A 26-year-old woman, with one previous cesarean delivery and two uterine curettage due to incomplete abortion, was admitted to the labor ward with the diagnosis of partial placenta previa at 35 weeks of gestation. Repeat cesarean section was performed due to profuse vaginal bleeding. Placenta previa percreta invading the bladder trigone was confirmed with cystotomy. As bilateral hypogastric artery ligation and supracervical hysterectomy performed were not successful in stopping the profuse bleeding, the abdomen was packed with laparotomy pads. Dilatation of the left ureter was noticed on the second postoperative day. Relaparotomy was performed to remove the pads, and placental invasion of the distal left ureter was noticed. Ureteroneocystostomy was performed. The postoperative course was uneventful, and the double-J-catheter was removed two months later.