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Helvacioglu C, Trabulus DC, Yardimci EAS, Turan H. Ruptured primary sigmoidal pregnancy; a case report. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2020. [DOI: 10.25083/2559.5555/5.1/56.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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2
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Diop B, Niang MM, Dia AA, Ba PA, Wilson E, Wane Y, Sarre SM. Abdominal Pregnancy Before 20 Weeks: Management Difficulties in Limited-Access Areas. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2016.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Balla Diop
- Department of Surgery, Ouakam Military Hospital, Dakar, Sénégal
- Department of Health Sciences, University of Thies, Thies, Sénégal
| | | | - Amadou Aliou Dia
- Department of Radiology, Ouakam Military Hospital, Dakar, Sénégal
| | - Pape Abdoulaye Ba
- Department of General Surgery, Regional Hospital Center of Thies, Thies, Sénégal
| | - Eric Wilson
- Department of Surgery, Ouakam Military Hospital, Dakar, Sénégal
| | - Youhanidou Wane
- Department of Gynecology, Ouakam Military Hospital, Dakar, Sénégal
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Shurie S, Ogot J, Poli P, Were E. Diagnosis of abdominal pregnancy still a challenge in low resource settings: a case report on advanced abdominal pregnancy at a tertiary facility in Western Kenya. Pan Afr Med J 2018; 31:239. [PMID: 31447996 PMCID: PMC6691312 DOI: 10.11604/pamj.2018.31.239.17766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/10/2018] [Indexed: 02/04/2023] Open
Abstract
Abdominal pregnancy is a rare form of ectopic pregnancy, occurring in 1: 10,000 to 1: 30,000 pregnancies and accounting for up to 1.4% of all ectopic pregnancies. It is classified as primary or secondary depending on the site of fertilization. However, when it does happen, it may remain unnoticed until term because the pregnancy can appear normal during clinical examination. Advanced abdominal pregnancy is associated with high mortality rate for both the mother and the baby at 1-20% and 40-95% respectively. We report a case of a 30-year-old female para 2+0, gravida 3 at 35+1 who presented at a Tertiary facility in Eldoret Kenya with one-day history of per vaginal bleeding and 2 weeks' history of no fetal movements. The importance of this case report is to highlight the challenges associated with diagnosis of advanced abdominal pregnancy in low resource settings. Ultrasound alone cannot be relied on to make the diagnosis. Whenever an induction is not working, abdominal pregnancy should be considered.
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Affiliation(s)
- Sahara Shurie
- Department of Reproductive Health, College of Health Sciences Moi University, Eldoret, Kenya
| | - John Ogot
- Department of Reproductive Health, College of Health Sciences Moi University, Eldoret, Kenya
| | - Philippe Poli
- Department of Reproductive Health, College of Health Sciences Moi University, Eldoret, Kenya
| | - Edwin Were
- Department of Reproductive Health, College of Health Sciences Moi University, Eldoret, Kenya
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4
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Hymel JA, Hughes DS, Gehlot A, Ramseyer AM, Magann EF. Late Abdominal Pregnancies (≥20 Weeks Gestation): A Review from 1965 to 2012. Gynecol Obstet Invest 2015; 80:253-8. [PMID: 25924581 DOI: 10.1159/000381264] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 02/26/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Information about the diagnosis and management of late abdominal pregnancies (≥20 weeks gestation) is limited to case reports and small case series. METHODS We performed a literature review of abdominal pregnancies ≥20 weeks gestation from 1965 to November 2012. Excluded were abdominal ectopic pregnancies that did not primarily implant in the peritoneal cavity, including tubal, ovarian, and intraligamentary pregnancies, and those prior to 20 weeks gestation. RESULTS The 31 cases identified were at 30.4 ± 7.4 weeks at diagnosis and 33 ± 8.3 weeks at delivery. The most common sites of placental implantation were uterus or adnexa (47.8%), bowel (30%), and the potential spaces surrounding the uterus (8.7%). There were 5 cases of an intra-abdominal abscess in the 14 patients in whom the placenta had been left in situ. Maternal outcomes were documented in 26 cases with 7 deaths; 27 fetal outcomes were documented in 22 cases with 3 fetal deaths (13.6%). CONCLUSION An abdominal ectopic pregnancy is an uncommon but serious event and should be considered in all patients until intrauterine gestation is confirmed. Management should be undertaken by an experienced surgical team in a tertiary care facility.
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Affiliation(s)
- Jamie A Hymel
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Ark., USA
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5
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Laparoscopic management of an abdominal pregnancy. Case Rep Obstet Gynecol 2014; 2014:562731. [PMID: 25478262 PMCID: PMC4244937 DOI: 10.1155/2014/562731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 09/23/2014] [Accepted: 10/13/2014] [Indexed: 11/18/2022] Open
Abstract
Background. Ectopic pregnancy is one of the leading causes of significant maternal morbidity and mortality. Abdominal surgeries increase the risk of postoperative adhesions. We here present a case of omental ectopic pregnancy in a patient with a prior history of cesarean section. Case. A 20-year-old female presented with a two-day history of crampy lower abdominal pain. Patient was hemodynamically stable with a beta HCG of 1057 mI/mL. Transvaginal ultrasound did not show an intrauterine pregnancy but revealed an ill-defined mass in the midline pelvis extending to the right of the midline. Diagnostic laparoscopy revealed large clots in the pelvis with normal uterus and adnexa. Intra-abdominal survey revealed an omental adhesion close to the right adnexa with a hematoma. Partial omentectomy was completed and the portion of the omentum with the hematoma was sent to pathology for confirmation. Final pathology confirmed the presence of chorionic villi consistent with products of conception. Conclusion. Omental ectopic pregnancy is a rare diagnosis and often missed. We recommend careful intra-abdominal survey for an ectopic pregnancy in the presence of hemoperitoneum with normal uterus and adnexa. This can be safely achieved using laparoscopy in early gestational ages when the patient is hemodynamically stable.
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Smrtka MP, Gunatilake R, Miller MJ, Heine RP, Brown HL. Improving the management of an advanced extrauterine pregnancy using pelvic arteriography in a hybrid operating suite. AJP Rep 2012; 2:63-6. [PMID: 23946909 PMCID: PMC3653508 DOI: 10.1055/s-0032-1322507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 04/01/2012] [Indexed: 11/19/2022] Open
Abstract
Advanced extrauterine pregnancy is an extremely rare, life-threatening pregnancy complication. Management of these pregnancies presents significant challenges, especially when they have progressed to an advanced stage of fetal viability. With high rates of maternal and fetal mortality associated with this complication, delivery or pregnancy interruption should be expedited following diagnosis. Localization of the placenta and its blood supply is critical to preoperative planning. Hybrid operating suites that can accommodate a multidisciplinary team of subspecialists may improve the chance of a successful outcome with this rare complication.
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Affiliation(s)
- Michael P Smrtka
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
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7
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A 30-year review of advanced abdominal pregnancy at the Mater Misericordiae Hospital, Afikpo, southeastern Nigeria (1976–2006). Arch Gynecol Obstet 2009; 283:19-24. [DOI: 10.1007/s00404-009-1260-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2009] [Accepted: 10/08/2009] [Indexed: 11/24/2022]
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8
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Term extrauterine pregnancy in a Nigerian mother: a complication of uterine dehiscence. Arch Gynecol Obstet 2008; 279:75-7. [PMID: 18449557 DOI: 10.1007/s00404-008-0641-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2008] [Accepted: 03/21/2008] [Indexed: 10/22/2022]
Abstract
Abdominal pregnancy is an uncommon but life-threatening form of ectopic pregnancy. It is associated with high maternal/fetal morbidity and mortality. We present a rare case of term abdominal pregnancy resulting from anterior uterine wall dehiscence, in a 36-year-old woman with three previous caesarean sections. The diagnosis was made at laparotomy for the fourth "caesarean section".
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9
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Yi KW, Yeo MK, Shin JH, Kim KA, Oh MJ, Lee JK, Hur JY, Saw HS. Laparoscopic Management of Early Omental Pregnancy Detected by Magnetic Resonance Imaging. J Minim Invasive Gynecol 2008; 15:231-4. [DOI: 10.1016/j.jmig.2007.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Revised: 11/09/2007] [Accepted: 11/21/2007] [Indexed: 10/22/2022]
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10
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Dahiya K, Sharma D. Advanced Abdominal Pregnancy: A Diagnostic and Management Dilemma. J Gynecol Surg 2007. [DOI: 10.1089/gyn.2007.b-02259-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Krishna Dahiya
- Department of Obstetrics and Gynecology, Pandit Bhagwat Dayal Sharma, Post Graduate Institute of Medical Sciences (Pt.BDS, PGIMS), Rohtak, Haryana, India
| | - Damyanti Sharma
- Department of Obstetrics and Gynecology, Pandit Bhagwat Dayal Sharma, Post Graduate Institute of Medical Sciences (Pt.BDS, PGIMS), Rohtak, Haryana, India
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11
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Sherer DM, Dalloul M, Gorelick C, Kheyman M, Abdelmalek E, Zinn HL, Abulafia O. Unusual maternal vasculature in the placental periphery leading to the diagnosis of abdominal pregnancy at 25 weeks' gestation. JOURNAL OF CLINICAL ULTRASOUND : JCU 2007; 35:268-73. [PMID: 17436318 DOI: 10.1002/jcu.20375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Abdominal pregnancy is a rare condition in which the fetus and placenta are located within the peritoneal cavity. Sonographic findings include visualization of the fetus separate from the uterus, failure to visualize the uterine wall between the fetus and urinary bladder, close approximation of fetal parts to the maternal abdominal wall, eccentric position or abnormal fetal attitude, and visualization of extrauterine placental tissue. We present an unusual case in which mid-trimester transabdominal color Doppler sonographic findings depicted unusual maternal vasculature in the placental periphery leading to the diagnosis of abdominal pregnancy. Postpartum maternal angiography confirmed these vessels as abnormal maternal arterial perfusion of the extrauterine placenta emanating from the uterine arteries and inferior epigastric arteries. Systematic review of the literature confirms that this is the first report of such sonographic manifestations of an abdominal pregnancy.
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Affiliation(s)
- David M Sherer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, 445 Lenox Road, Box 24, Brooklyn, NY 11203, USA
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12
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Shojai R, Chaumoitre K, Chau C, Panuel M, Boubli L, d'Ercole C. Advanced Combined Abdominal and Intrauterine Pregnancy: A Case Report. Fetal Diagn Ther 2006; 22:128-30. [PMID: 17139169 DOI: 10.1159/000097111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Accepted: 04/11/2006] [Indexed: 11/19/2022]
Abstract
We present a case of simultaneous abdominal and intrauterine pregnancy following in vitro fertilization and embryo transfer diagnosed during the second trimester. The patient had a recent history of hysteroscopic metroplasty due to in utero exposition to diethylstilboestrol. The pregnancy was managed conservatively with a favorable outcome for the mother and both fetuses.
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Affiliation(s)
- R Shojai
- Department of Obstetrics and Gynecology, Hopital Nord, Marseille, France.
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13
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Lenglet JE, Bekker MN, Akkerman C, Bolte AC, van Vugt JMG. Prenatal ultrasound and MRI predict placental localization in a combined intrauterine and extrauterine twin pregnancy. Prenat Diagn 2006; 26:376-8. [PMID: 16566055 DOI: 10.1002/pd.1403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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14
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Roberts RV, Dickinson JE, Leung Y, Charles AK. Advanced abdominal pregnancy: still an occurrence in modern medicine. Aust N Z J Obstet Gynaecol 2005; 45:518-21. [PMID: 16401220 DOI: 10.1111/j.1479-828x.2005.00489.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In a world bewildered by spectacular advances in imaging technology, the early detection of an abdominal pregnancy should be a feasible objective. A case of an advanced abdominal pregnancy is presented. Although the pregnancy was the result of in vitro fertilisation technology, the diagnosis was not suspected until 35 weeks gestation. Both ultrasound and magnetic resonance imaging (MRI) were used to achieve a diagnosis prior to delivery. The placenta was left within the peritoneal cavity but removal was necessitated for maternal symptomatology 4 months postdelivery. This case illustrates that despite the almost ubiquitous usage of prenatal ultrasound, extrauterine pregnancies may not be detected in a timely manner unless attention to basic ultrasound techniques is followed.
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Affiliation(s)
- Rae V Roberts
- King Edward Memorial Hospital for Women, The University of Western Australia, Perth, Australia
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15
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Hughes S, Goodyear P, Sansome A. The anaesthetic management of a woman with a 31-week abdominal pregnancy. Int J Obstet Anesth 2004; 10:321-4. [PMID: 15321592 DOI: 10.1054/ijoa.2001.0855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
An 18-year-old primigravida was admitted to hospital complaining of abdominal pain and vomiting. An ultrasound examination suggested the diagnosis of advanced abdominal pregnancy and this was confirmed using magnetic resonance imaging. Two days later she underwent operative delivery of a live fetus. The placenta was left in situ as it was attached to a large number of pelvic structures. Such surgery can result in maternal death due to massive haemorrhage as there is no mechanism to stem blood loss from the placental bed. Death can also occur in the post-partum period from septic complications if the placenta is left in situ. The management of such patients requires personnel and equipment to deal with massive and rapid haemorrhage; aortic cross clamping may be required to control bleeding. In this case, surgery and recovery were uneventful.
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Affiliation(s)
- S Hughes
- Shackleton Department of Anaesthetics, Southampton General Hospital, Temona Road, Southampton, SO16 6YD, UK.
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16
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Beddock R, Naepels P, Gondry C, Besserve P, Camier B, Boulanger JC, Gondry J. [Diagnosis and current concepts of management of advanced abdominal pregnancy]. ACTA ACUST UNITED AC 2004; 32:55-61. [PMID: 14736602 DOI: 10.1016/j.gyobfe.2003.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Authors report a case of abdominal pregnancy diagnosed by MRI at 17 SA with prospective follow-up and planned delivery at 37 SA. The diagnosis is clinically suspected when extra-uterine pregnancy risk factors or history of uterine trauma are present. This is confirmed by MRI, which may be considered as the gold standard. A conservative management may be proposed when the diagnosis is made after 20 weeks and under the following conditions: absence of fetal growth malformation, placental implantation remote from the upper abdomen, good maternal condition, close management in a hospital setting of the patient previously informed of the risks and outcomes. Placental location on the uterus seems to be a major positive factor of outcome for these pregnancies. Materno-fetal follow-up is based on physical examination, repeated ultrasonic investigations with Doppler imaging and daily fetal heart rate monitoring. In the absence of complications, a laparotomy should be planned at 34 weeks. The placenta may not be removed when a serious risk of hemorrhage is feared.
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Affiliation(s)
- R Beddock
- Centre de gynécologie et obstétrique, CHU d'Amiens, 124, rue Camille-Desmoulins, 80054 Amiens 1, France.
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17
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Varma R, Mascarenhas L, James D. Successful outcome of advanced abdominal pregnancy with exclusive omental insertion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2003; 21:192-194. [PMID: 12601846 DOI: 10.1002/uog.25] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
We report the case of an advanced abdominal pregnancy with exclusive omental insertion whose extrauterine location was not established until delivery by Cesarean section at 35 weeks' gestation. It is hard to believe that omental placentation alone would be sufficient to sustain a pregnancy beyond a gestation where the fetus is viable. However, this report challenges such myths and opens the debate as to what represents the minimal placental maternal viscus contact necessary to achieve fetal viability. The case also demonstrates the continuing difficulty in diagnosing this rare but serious condition despite advances in obstetric imaging, and advocates methods to avoid missing the diagnosis, which could be easily incorporated at booking and mid-trimester scans. Apart from this case, few reports describe normal umbilical artery Doppler velocimetry in advanced abdominal pregnancy. There is a paucity of research on suitable clinical investigations prognostic for abdominal pregnancy, although this case provides further evidence for the use of Doppler as a useful surveillance tool in such cases. Finally, this case propagates the ethical and clinical controversy that exists in managing abdominal pregnancy, particularly when diagnosed late after attaining fetal viability. Expectant management may represent a feasible alternative to surgical termination provided the woman is fully informed of the attendant risks and close surveillance of the pregnancy is undertaken.
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Affiliation(s)
- R Varma
- Department of Obstetrics and Gynaecology, Bedford Hospital, Bedford, UK.
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18
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Valenzano M, Nicoletti L, Odicino F, Cocuccio S, Lorenzi P, Ragni N. Five-year follow-up of placental involution after abdominal pregnancy. JOURNAL OF CLINICAL ULTRASOUND : JCU 2003; 31:39-43. [PMID: 12478651 DOI: 10.1002/jcu.10124] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
A 29-year-old woman with an abdominal pregnancy was admitted to the hospital at 29 weeks' menstrual age. At 30 weeks, laparotomy was performed, and a live fetus, wrapped in membrane remnants, was taken from the abdominal cavity. The placenta, inserted in the right hemipelvis, was left in situ. The patient's postoperative recovery was uneventful, and she was monitored periodically as follow-up. At her 5-year follow-up visit, we assessed placental involution by measuring serum beta human chorionic gonadotropin and by using color and pulsed Doppler sonography. The dynamics of the regression of placental volume yielded a bimodal curve: a phase of decrease over the first 2 months, coincident with a reduction in vascularization, followed by stability that lasted 6-8 months, and a second phase of gradual volume reduction. At 5 years, the placenta appeared as a small residual echogenic mass with no vascularity. The use of MRI in this case provided no additional information to what we found using sonography.
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Affiliation(s)
- Mario Valenzano
- Department of Gynecology and Obstetrics, University of Genoa, Piazza R. Benzi 2, 16132 Genoa, Italy
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20
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Carpenter T, Evans P, Wheeler T. An unusual mode of delivery. BJOG 2001; 108:436-7. [PMID: 11305557 DOI: 10.1111/j.1471-0528.2001.00084.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- T Carpenter
- Department of Obstetrics and Gynaecology, Princess Anne Hospital, Southampton, UK
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21
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Abstract
MRI is a proven modality to evaluate the female pelvis. Excellent soft tissue contrast, sensitivity for the detection of fluid, and the multiplanar imaging capabilities of MR allow noninvasive demonstration of normal anatomy and pathological processes. Most female pelvic MRI studies are performed to answer specific questions and must, therefore, follow carefully developed protocols, which are discussed in this article. The principal MRI techniques and strategies outlined in this work include: (1) the evaluation of reproductive dysfunction, anatomic variants; (2) specific obstetrical applications; (3) oncologic evaluation and tumor staging; (4) problem solving (i.e., the characterization of abnormalities detected by ultrasound); and (5) the evaluation of urethral disease.
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Affiliation(s)
- A M Kennedy
- Department of Radiology, University of Utah Medical Center, Salt Lake City 84132, USA
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Lepers S, Besserve P, Montravers P. [Anesthetic management for delivery of an abdominal pregnancy]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1999; 18:530-3. [PMID: 10427386 DOI: 10.1016/s0750-7658(99)80126-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We report the anaesthetic management of an abdominal pregnancy. The delivery was obtained by laparotomy, under general anaesthesia, by a multi-specialist team. Abdominal pregnancy carries a high foetal and maternal risk for morbidity and lethal outcome. The main complication is sudden haemorrhage which can occur at any time.
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Affiliation(s)
- S Lepers
- Département d'anesthésie-réanimation chirurgicale B, centre hospitalier général, Boulogne-sur-Mer, France
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