Medical management of ectopic pregnancy.

The use of medical management of ectopic pregnancy has become an accepted alternative to surgical therapy. Methotrexate, a folic acid antagonist, is the most widely studied agent. The most commonly used protocol consists of methotrexate 50 mg/m of actual body weight.

Diagnosis of ectopic pregnancy.

The declining death rate from ectopic pregnancy over the last 30 years has resulted not from improvements in operative technique, anesthesia, or blood banking but primarily due to more rapid diagnosis that allows for earlier treatment. Algorithms have been developed to eliminate delays in ordering the various diagnostic tests in the appropriate order. Diagnostic tests include serum human chorionic gonadotropin and progesterone levels, culdocentesis, dilatation and curettage, transvaginal ultrasound, and laparoscopy.

Endometrioma occurring in abdominal wall incisions after cesarean section.

Objective: To investigate outcomes following incisional endometrioma after cesarean section and correlate the role of predisposing factors.

Study Design: Chart review of patients from a 7-year period noting surgical history, previous incisions, uterine exteriorization, and wound irrigation at cesarean section, preoperative and final endometrioma size, mass location, fascial involvement, and mesh placement.

Results: All 16 patients had cesarean section as their last surgery and 15 of 16 had transverse incisions.

Preventing electrosurgical energy-related injuries.

Electrosurgery is used on a daily basis in the operating room, but it remains poorly understood by those using it. In addition, the physics of electrosurgery are far more complicated than those of laser. Common belief notwithstanding, electrosurgery has an enormous capacity for patient injury if used incorrectly, even though technology has markedly reduced the likelihood of patient or surgeon injuries.

Abdominal wall abscess presenting 35 years after insertion of an intrauterine contraceptive device.

Background: Intrauterine devices (IUDs) are an effective means of contraception for many women worldwide. However, complications of insertion, such as uterine perforation, can lead to significant intraabdominal problems. We present a case of an abdominal wall abscess caused by an IUD 35 years after insertion.

Yolk sac on transvaginal ultrasound as a prognostic indicator in the treatment of ectopic pregnancy with single-dose methotrexate.

Objective: To determine whether yolk sac on transvaginal ultrasound was an independent predictor for single-dose methotrexate failure for tubal ectopic pregnancies.

Study Design: Seven hundred sixty-six consecutive methotrexate-treated ectopic pregnancy patients were reviewed. After excluding 25 oral and 97 multidose methotrexate patients, 18 cornual, 4 cervical pregnancies, and 63 patients with ectopic cardiac activity, 559 study patients remained.

Medical therapy for ectopic pregnancy.

Methotrexate for treatment of ectopic tubal pregnancy has become an accepted alternative to surgical options. Methotrexate is a folic acid analog that interferes with DNA synthesis. Protocols using planned multiple doses of methotrexate alternating with citrovorum rescue factor and one protocol using only a single planned dose are both currently used in the treatment of ectopic pregnancy.

Retained fetal parts after elective second-trimester dilation and evacuation.

Background: Extrusion of fetal parts into the abdomen after second-trimester pregnancy termination is rare.

Case: We report a case of extrusion of fetal parts into the broad ligament at the time of second-trimester pregnancy termination that remained undetected for 10 days.

Conclusion: In cases of perforation during second-trimester pregnancy termination, meticulous evaluation of the abdomen and pelvis with ultrasonography or computerized tomography should be performed if complete fetal evacuation cannot be confirmed.

Ureteral avulsion during uterine dilatation and evacuation: a case report.

Background: Ureteral injury during elective pregnancy termination is rare and has been reported only 8 times. Two of these cases involved avulsion, and 1 occurred during a second-trimester procedure.

Case: Ureteral avulsion and damage to the lower colon occurred during second-trimester pregnancy termination.

A trial that compares Monsel's paste with ball electrode for hemostasis after loop electrosurgical excision procedure.

Objective: The purpose of this study was to compare Monsel's paste with fulguration with ball electrode for hemostasis after loop electrosurgical excision procedure.

Study Design: One hundred healthy women were assigned randomly by computer-generated random numbers to ball electrode or thickened Monsel's paste for hemostasis after loop electrosurgical excision procedure. Patients rated pain during hemostasis using a visual analog scale.

Torsion of the appendix mimicking ovarian torsion.

Background: Appendiceal torsion is rare and generally seen more frequently in children than adults. Untreated it can lead to necrosis, ulceration, and subsequent peritonitis.

Case: A middle-aged female presented with a 5-day history of cramping abdominal pain and nausea and vomiting.

Comparison of multidose and single-dose methotrexate protocols for the treatment of ectopic pregnancy.

Objective: The purpose of this study was to compare success rates of 643 patients who had ectopic pregnancy from the same database who were treated with multidose or single-dose methotrexate protocols.

Study Design: We compared demographics, gestational age, serum human chorionic gonadotropin, progesterone levels, ectopic sac size and volume, overall ectopic mass size and volume, ectopic cardiac activity, history of ectopic pregnancy, number of treatment days, methotrexate doses, and outcome in consecutive patients with ectopic pregnancy who were treated with methotrexate.

Results: Success rates were comparable between patients with multidose and single-dose therapy (95% vs 90%, respectively) as were human chorionic gonadotropin and progesterone levels, history of ectopic pregnancy (21.

Previous ectopic pregnancy as a predictor of failure of systemic methotrexate therapy.

Objective: To investigate whether a history of previous ectopic pregnancy is an independent risk factor for failure of methotrexate therapy in subsequent ectopic pregnancies and whether the previous treatment method influenced failure.

Setting: Inner-city teaching hospital.

Design: Retrospective case review.

Cefazolin versus cefazolin plus metronidazole for antibiotic prophylaxis at cesarean section.

Background: Although prophylactic antibiotic medications have been shown to reduce the incidence of postoperative infectious morbidity after cesarean delivery, the most effective regimens have not been established. The purpose of this investigation was to compare the efficacy and costs of prophylaxis with cefazolin alone with cefazolin plus metronidazole.

Methods: Women undergoing cesarean delivery were randomized to prophylaxis with 2 g cefazolin (n = 81) or 1 g cefazolin plus 500 mg metronidazole (n = 79).

Is a resident's score on a videotaped objective structured assessment of technical skills affected by revealing the resident's identity?

Objective: The purpose of this study was to determine whether knowledge of resident's identity affects the evaluation of surgical skills.

Study Design: During an objective structured assessment of technical skills, 33 residents in obstetrics and gynecology who performed 10 surgical skills were videotaped with two digital cameras simultaneously. One camera videotaped "hands only," concealing resident identity; the other camera videotaped from the "waist up," revealing identity.

A randomized trial of postoperative wound irrigation with local anesthetic for pain after cesarean delivery.

Objective: The purpose of this study was to investigate the efficacy of continuous local anesthetic infusion system for pain control after cesarean delivery.

Study Design: This was a randomized prospective double-blind study. Patients who underwent cesarean delivery had a pain system implanted subcutaneously after closure of the fascia.

Molar cornual ectopic pregnancy.

Background: Few cases of ectopic molar pregnancies have been reported. We present one such case of a molar cornual pregnancy.

Case: A woman at 12 weeks' gestation by last menstrual period presented with ultrasound evidence of a molar pregnancy and a surgical abdomen.

Management of separation pain after single-dose methotrexate therapy for ectopic pregnancy.

Objective: To review the success of conservative management of moderate to severe abdominal/pelvic pain occurring after treatment of ectopic pregnancy with systemic methotrexate, to evaluate prognostic factors for success, and to determine if the overall resolution time was shorter in such patients.Methods: A retrospective chart review of all single-dose methotrexate patients treated from January 1, 1992 to January 1, 1997 who were admitted for observation or evaluated and subsequently discharged after an episode of increased abdominal/pelvic pain unrelieved within 1 hour by 800 mg oral ibuprofen. Before 1992, patients developing such pain generally underwent surgery.