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This report presents a case of pelvic actinomycotic infection that was accurately diagnosed preoperatively by means of fine needle aspiration. The patient was a 40-year-old black female, gravida 6, para 6, who presented to the emergency room complaining of intermittent, crampy lower abdominal pain of approximately 1 month's duration. She also complained of a recent onset of urinary frequency and urgency without dysuria as well as a change in bowel habits, with recent constipation. Review of the patient's medical history was notable for the placement of a Dalkon Shield IUD 10 years before without subsequent removal, a history of irregular menses in the past year, and treatment for gonorrhea 10 years previously. The patient's last menstrual period was 2 weeks prior to admission. She denied fever and night sweats but had lost 20 pounds in the past 2-3 months. Vital signs were normal. Pelvic examination revealed a firm, fixed uterus, approximately the size of a 14-week pregnancy, and an associated mass extending to the left and inferiorly into the rectovaginal septum. An intravenous pyelogram showed left hydronephrosis and hydroureter, with compression of the ureter at the level of the sacrum. Sigmoidoscopy revealed extrinsic compression of the rectum at 12 cm, the some mucosal edema. A CT scan of the pelvis disclosed an 8 cm mass in continuity with the uterus extending into the lower pelvis, with possible focal erosion of the sacrum. The clinical impression was advanced cervical carcinoma. Transvaginal fine needle aspiration was performed using a 21-gauge spinal needle and a Franzen needle guide. Following a diagnosis of actinomycotic abscess, the patient was placed on tetracycline, due to her penicillin allergy, and taken to surgery. The abdomen was opened and revealed a slightly enlarged uterus. The uterus and cervix were adherent to the left pelvic wall and posteriorly to the rectum by firm, friable tissue. The left fallopian tube and ovary were adherent to this . With some difficulty the uterus was freed, and a total hysterectomy and bilateral salpingo-oophorectomy were performed. The postoperative course was unremarkable, and the patient was discharged on tetracycline. A morphologic diagnosis of actinomycotic infection with abscess formation was made. Sections of the left parametrium revealed multiple microabscesses and sinus tracts surrounded by abundant granulation tissue. Some of the abscesses contained actinomycotic organisms. Chronic endometritis and cervicitis as well as acute and chronic left salpingitis were documented.
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PMID:Diagnosis of pelvic actinomycosis by fine needle aspiration. A case report. 620 95

This article examines causal factors of ectopic pregnancy, discusses management with emphasis on tubal conservation, and updates information on diagnosis, fertility maximization, and minimization of risks of recurrent ectopic gestations. The common factor in ectopic gestations appears to be a delay in the transport of the fertilized ovum to the uterus, allowing the embryo to develop invasive trophoblast. Factors that appear to have increased the incidence of ectopic pregnancy over the past include increased sexual exposure, more effective theraphy for pelvic inflammatory disease, IUDs, tubal surgery, and surgical sterilization reversals. 77% of extrauterine gestations occur in the middle and distal thirds of the fallopian tube, with clinical manifestations largely determined by the site of implantation. Abdominal pain, amenorrhea/vaginal bleeding, and a pelvic mass are the classic signs of an ectopic pregnancy. Newer diagnostic procedures including serum human chorionic gonadotropin-beta subunit assay pregnancy testing supported by ultrasonography and laparoscopy have allowed the vast majority of tubal pregnancies to be diagnoses before rupture, permitting surgery to be undertaken more for the purpose of preserving fertility than for saving the mother's life. Factors in selecting candidates for conservative surgery include medical stability of the patient, parity, desire for future pregnancy, age under 35, mid or distal tubal gestation, prior ectopic gestation or tubal surgery. Considerations influencing the surgical approach for appropriate candidates include location of the pregnancy, condition of the involved and contralateral tube and ovary, pelvic anomalies, previous surgery, and need for ancillary procedures. If the ectopic gestation is located in the mid to distal segment of the fallopian tube, a segmental resection or salpingostomy using microsurgery should give a good anatomic and functional result. A review of the literature indicates that, contrary to prevailing opinion, recurrent etopic gestations are not more common in patients undergoing tubal conservation than in those undergoing more radical procedures. Recent data have shown term pregnancy rates of 40-55% and recurrent ectopic pregnancy rates of 5% in patients with conservative procedures, the improved rate being attributed to availability of microsurgical techniques, finer suture and minimal surgical trauma, which lead to less adhesions and scarring. tudies have indicated that use of Dextran minimizes pelvic adhesion formation, decreasing anatomic distortion leading to subsquent infertility or ectopic pregnancy.
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PMID:Tubal conservation with ectopic gestations. A reappraisal. 623 72

In a review of the world's literature on combined intrauterine and extrauterine pregnancies, 589 cases, including five cases currently reported from the Sloane Hospital for Women, were documented. Analysis of the literature revealed abdominal pain to be the most frequent presenting symptom. A combination of signs and symptoms, including abdominal pain, adnexal mass, peritoneal irritation, and an enlarged uterus, was the most significant finding in support of a presumptive diagnosis of combined gestations. At the Sloane Hospital for Women, the occurrence of both pelvic inflammatory disease and combined pregnancy is approximately three times the reported world incidence. This proportionate increase in both disease states may support a potential etiologic association between pelvic inflammatory disease and simultaneous intrauterine and extrauterine gestations.
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PMID:Combined intrauterine and extrauterine gestations: a review. 634 38

This discussion of acute pelvic inflammatory disease (PID) -- usually a spontaneous infection that occurs among sexually active, menstruating, nonpregnant women -- covers: pathophysiology; microbial etiology (gonorrhea, chlamydia, genital mycoplasmas, and aerobic and anerobic bacteria); epidemiology (number of sexual partners, age, IUDs, previous PID, previous gonorrhea, untreated male sexual contacts, and perihepatitis associated with PID); diagnosis (physical examination, laboratory examination, culdocentesis, examination of the male partner, cultures, and ultrasonography); treatment; and sequelae (recurrent PID, infertility, ectopic pregnancy, and pain). The majority of infections are caused by bacteria and a polymicrobial bacterial infection is common. Neisseria gonorrhea, Chlamydia trachomatis, and a wide variety of aerobic and anerobic bacteria are most frequently isolated from women with PID. Primary PID is usually and acute infection in which organisms ascend into the uterus and fallopian tubes from the cervix. Chronic active infections are unusual except in neglected cases and in Actinomyces infection, but sterile chronic inflammatory adhesions are common residuals of acute infection. Except for women who have an IUD in place or the 15% who have had uterine instrumentation, spontaneous PID is almost totally confined to women who are sexually active. There is a much higher PID rate among younger than older women. Women who use an IUD for contraception are at least 2-4 times more likely to develop PID than nonusers. Women who have had PID are twice as likely to develop the infection as those who have never had it. A history of a prior uncomplicated gonococcal infection is more common among women with PID than among women without disease. Untreated males with urethral N. gonorrhea and possibly with C. trachomatis infection are an important source of infection both for the initial and for recurrent episodes of PID. Abdominal pain is the most common symptom although the pain may be mild or even absent in at least 5% of patients with PID verified by laparoscopy. In patients who have overt PID, it is possible to establish the diagnosis with reasonable certainty by a combination of history, physical examination, Gram stain of cervical secretions, culdocentesis, and examination of the male sexual partner. Adequate treatment of salpingitis includes an assessment of the severity of the infection, administration of appropriate antibiotics, employment of other health measures, close patient follow-up, and treatment of the male sexual patner. 25% of women with 1 episode of salpingitis develop a subsequent episode.
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PMID:Acute pelvic inflammatory disease. 636 7

A 48-year-old woman came to our hospital with complaint of macroscopic hematuria and left lower abdominal pain, on January, 27, 1982. She complained of lower abdominal oppressive pain, but no abdominal tumor was palpated on physical examination. Vaginal examination revealed a stony hard and nodular tumor which was not movable, and as large as a man's fist, on the left side of uterine cervix. IVP revealed left nonfunctioning kidney. Cystoscopy revealed no abnormal finding but left ureteral catheterization could not be done. CTscan revealed intrapelvic homogenous mass which could not be identified from uterus. Pelvic angiography revealed an encasement of the left uterine artery, and moderate hypervascular tumor which deviated the obturatorius artery. Under the diagnosis of retroperitoneal tumor, operation was done on March, 8, 1982. The tumor existed in the retroperitoneal space, and was as large as a man's fist. It was not a movable mass, venous dilatation was found on its surface, and severe adhesion was found between the lateral side of the tumor and the left external iliac artery. So only biopsy was done. Histopathological diagnosis of the specimen was hemangiopericytoma. She received postoperative radiation therapy with total dose 5,000rad in 5 weeks. Now about 2 years have passed, vaginal examination revealed no tumor, and CTscan revealed diminishment of the tumor. Generally radiotherapy is not considered to be effective for hemangiopericytoma, but sometimes it is. Thus preoperative vascular embolization with surgical resection and postoperative radiotherapy or chemotherapy are considered to be necessary for successful treatment of hemangiopericytoma.
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PMID:[Case of radiation treatment in retroperitoneal hemangiopericytoma]. 648 75

Angular pregnancies which result from implantation of the fertilised oocyte in the mucosa of a uterine horn are very rare. They are usually demonstrated by a picture of rupture which is associated with severe abdominal pain, the syndrome of internal haemorrhage, often a state of shock and all occurring usually between the 6th and the 12th week of pregnancy. Although many authors have shown that there is congenital abnormality of the uterus in these cases this does not always happen and the aetiology of "idiopathic angular pregnancies" is ill understood. The treatment is carried out according to the clinical state: endometrial curettage under laparoscopic control, removal of the uterine horn together with the tube on the same side or even hysterectomy.
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PMID:[Ruptured angular pregnancy in the 16th week. Apropos of a case]. 652 81

Information from 2 recent books on the most common abortion techniques is presented. Menstrual aspiration can be performed up to 14 days after a missed period. A flexible plastic cannula 4-5 mm in diameter is passed through the cervix to the uterus, and the contents are evacuated using a syringe. Little dilatation is required and the procedure is done under local anesthesia. Aspiration through the 12th week is usually done under general anesthesia using a cannula and mechanical aspiration. A curette is used to assure that the abortion is complete. Local anesthesia is used in some places. From 12-16 weeks a combination of scraping and aspiration is used with general anesthesia and sometimes forceps. The uterine cervix requires greater dilatation. After 16 weeks the amniotic fluid is removed and a solution of salt and water is injected into the woman under local anesthesia. Contractions begin about 24 hours later. Labor may also be induced by oxytocin or prostaglandins which result in 8-15 hours of labor. This method of abortion probably causes the greatest amount of anxiety in the patient. Uterine scraping is described in the 2nd book as a procedure in which the cervix is progressively dilated with metal instruments of different sizes until it is sufficiently dilated to permit passage of the curette. Laminaria tents were previously placed in the cervix 24 hours prior to the abortion to achieve slow and progressive dilatation. General anesthesia is required because cervical dilatation is painful. In uterine aspiration the contents of the uterus are removed using tubes called Karmen cannulas. It is sometimes possible to avoid cervical dilatation by using thin cannulas, in which case general anesthesia may be avoided. After the aspiration the uterus may be scraped to assure the complete removal of the uterine contents. Prostaglandins may be used to initiate uterine contractions leading to expulsion of the uterine contents during the 2nd trimester of pregnancy. The procedure may cause significant side effects. Other procedures consist of injecting various substances into the uterine cavity during the 2nd trimester of pregnancy. Hysterotomy involves surgical opening of the abdomen and is analogous to cesarean section. Possible complications of an induced abortion include uterine perforation, bleeding, infection, and in extreme cases maternal death through sepsis. Medical attention should be sought in cases of hemorrhage, abdominal pain, fever, or general malaise after an induced abortion.
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PMID:[Literary but technical abortion]. 655 11

The incidence, clinical presentation, diagnosis, and treatment of 2 problems of early pregnancy--spontaneous abortion and ectopic pregnancy--are reviewed. The incidence of spontaneous abortion is reported to be 10-20% of all pregnancies and may be decreasing. Abnormal development of the pregnancy, unsuccessful implantation, maternal disease, noxious agents, previous surgery, abnormalities of the genital tract, and psychological stress have all been implicated in the etiology of spontaneous abortion. The clinical presentations include threatened, inevitable, incomplete, complete, missed, septic, and habitual abortion. The management of threatened abortion has changed from strict limitations of activity and the use of progestational agents to more liberal recommendations regarding activity and the avoidance of progestins. Combined use of radioimmunoassay for the beta subunit of human chorionic gonadotropin and ultrasound examination of the pelvis can lead to accurate prediction of the pregnancy outcome in patients with 1st trimester bleeding. Evacuation of the uterus is the treatment of choice in inevitable or incomplete abortion. Clinicians should be aware of the guilt feelings, grief reactions, and fears about future pregnancies that often follow spontaneous abortion. Reports of the incidence of ectopic pregnancy have ranged from 1 in 250 to 1 in 70 pregnancies, and the rate has been increasing. The significant morbidity and mortality associated with this condition make early diagnosis essential. The 3 most common symtoms are abdominal pain, amenorrhea, and abnormal vaginal bleeding. Ultrasonography and new methods of measuring human chorionic gonadotropin facilitate early diagnosis. Culdocentesis remains the definitive method of diagnosis. Earlier diagnosis has led some physicians to advocate salpingostomy via laparoscopy rather than salpingectomy for treatment in selected cases.
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PMID:Spontaneous abortion and ectopic pregnancy. 655 28

An unusual case of pelvic abscess characterized by a relatively mild clinical course and unusual localization occurred in a previously healthy, married, 26-year old woman with 2 children and 1 previous abortion. The woman was admitted to the hospital for lower abdominal pain of 1 week's duration. A Lippes Loop C inserted 5 years earlier, 4 months after a term delivery, had caused no complications. The last menstrual period was 2 weeks before admission. 1 week before admission lower abdominal cramps and dysuria had started, and nitrofurantoin 400 mg daily was prescribed for suspected urinary tract infection. The patient was hospitalized when the pain worsened. The patient appeared well on admission. Abdominal examination disclosed a very tender suprapubic mass the size of a 14-week pregnancy. Vaginal examination revealed an anterior, normal-sized uterus adherent to the mass. An examination under general anesthesia revealed a 12 cm mass adherent to a normal sized uterus. Multiple adhesions prevented visualization of the pelvic organs during laparoscopy. The IUD was removed and sent for bacteriologic examination. Laparotomy revealed a mass with a diameter of 10 cm located between the bladder and the uterus and adherent to them and to the anterior abdominal wall. The tubes were hyperemic and edematous, and pus was noted in both fimbriae. Both ovaries appeared normal. The mass was excised and a frozen section examination established the diagnosis of an abscess, which was later confirmed by histopathologic examination. A course of intravenous gentamycin, ampicillin, and clindamycin was started. Polymicrobial infection with Streptococcus viridans, Staphylococcus, coagulase negative, and diptheroids was subsequently established. The postoperative course was uneventful, and physical examination a month later was normal. No explanation of the unusual location of the abscess in the visicouterine space or of the absence of most of the symptoms of an abscess was found.
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PMID:Pelvic abscess associated with a Lippes loop. An unusual case. 663 39

The case of small bowel incarcerated within the uterine cavity following a legal abortion is presented. The case, a 26-year old woman, gravida 5, para 4, was aborted with a rigid-type plastic suction cannula at 13 weeks after her last menstrual period. During the 1st hour after the procedure, the patient developed severe abdominal pain and vomiting. The uterus was felt to be 18 weeks in size, firm, and tender. Sonographic examination revealed multiple well-defined round cystic structures within the uterine cavity. At laparotomy, incarcerated and partially gangrenous small intestine was found in an intrauterine location. The perforation had occurred in the anterior fundal region, distant from the uterine scars from the case's 4 previous cesarian sections. This case illustrates a rare and serious complication of abortion and demonstrates the utility of sonography in postprocedure symptomatic patients. No other such cases have been reported in the literature.
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PMID:Intrauterine incarcerated bowel following uterine perforation during an abortion: a case report. 665 Jun 37


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