Empty Uterus Research Articles

Case Report: Acute Abdomen Due to Ruptured Ovarian Ectopic Pregnancy at 8 Weeks

Background Ovarian pregnancy is a rare type of ectopic pregnancy, accounting for 0.5% to 1% of all ectopic pregnancies, with an incidence ranging from 1 in 2,100 to 1 in 60,000 pregnancies. Due to its rarity and the lack of common risk factors, diagnosing ovarian pregnancy is often challenging and typically occurs during surgical exploration. Case Presentation We present the case of a 40-year-old woman who experienced severe pelvic pain, light vaginal bleeding, and 8 weeks of amenorrhea. Upon arrival at the hospital, she was hemodynamically unstable, with low blood pressure and a rapid heart rate. An ultrasound revealed an empty uterus, an irregular mass on her right ovary, and free fluid in the pelvis. Her beta-hCG level was elevated, and her hemoglobin level was low. Given the suspicion of an ectopic pregnancy, she underwent emergency surgery. During the operation, the surgical team discovered a large amount of clotted blood and a ruptured mass on her left ovary measuring 10 x 9.5 cm. Due to heavy bleeding, they performed a left oophorectomy and salpingectomy. Histopathological analysis later confirmed the diagnosis of ovarian pregnancy. Conclusion This case underscores the challenges in diagnosing ovarian pregnancy and highlights the necessity for prompt surgical intervention, particularly in unstable patients. Early detection and appropriate management are critical to prevent life-threatening complications.

Intrauterine device (IUD) migration to the fallopian tube: a rare location for a translocated IUD with no visceral injury

BackgroundLoss of Intra Uterine Device (IUD) following silent perforation of the uterus either during or after IUD insertion is an uncommon finding due to a lack of immediate follow-up. We report a rare case in which uterine perforation following the migration of IUD to the right fallopian tube without visceral injury. The patient presented with lower abdominal pain and pain during sex for one year since IUD insertion. On examination, we noted tenderness on the right suprapubic region and on speculum examination, no IUD thread was seen. A radiological pelvic examination showed an empty uterus without an IUD. Laparotomy and retrieval of migrated IUD was done followed by repair of perforated uterus.ConclusionMigrated IUD with silent uterine perforation without visceral injury is a distressing clinical condition both to the patient and the clinician. This case is reported to increase awareness in doing immediate vaginal examination and pelvic ultrasound post-IUD insertion.

Early diagnostis of splenic ectopic pregnancy: A case report and review literature

Splenic ectopic pregnancy is extremely rare but carries a high risk of life-threatening intraperitoneal bleeding. Here, we present a 40-year-old woman presenting with vaginal bleeding. Although the intrauterine device (IUD) had been in place for 6 years, urinary and serum tests were positive for pregnancy. However, transvaginal ultrasound showed an empty uterus, no apparent adnexal masses or free fluid. An abdominal ultrasound was subsequently performed, which revealed a viable gestational sac in the spleen. An MRI that did not induce ionizing radiation was also performed, confirming the diagnosis of this splenic pregnancy. The gastrointestinal surgeon completed a laparotomy which successfully removed the spleen's superior pole containing an ectopic pregnancy.

Unusual Case of Vaginal Bleeding in A Teenager Caused by Endometrial Cast: Case Report and Literature Review

Introduction Endometrial cast, a rare occurrence in gynaecology, is the expulsion of the near entirety of the endometrial lining of the uterine cavity, often maintaining the shape of the uterus. Also known as membranous dysmenorrhoea and largely associated with use of a progesterone-containing contraceptive; some cases following oral contraceptive pills (OCP) use in adolescence for the management of heavy menstrual bleeding (HMB), have been reported. Case Report A 16-year-old nulliparous girl presented with a sudden passage of tissue per vagina (PV) following a short duration of PV bleeding and short-lasting crampy abdominal pain, after a 3-month regular use of Rigevidon® (a combined oral contraceptive pill (OCP) containing ethinylestradiol and levonorgestrel): a contraceptive choice. Noted was a previously normal menstrual cycle following menarche at age 12 with an unremarkable past medical history, a negative urine pregnancy test and an empty uterus on ultrasound scan. Histological examination of the 14cm-long flat fleshy mass with an intrauterine outline confirmed an endometrial or decidual cast. Discussion Cast formation, with different underlying mechanisms – inadequate estrogen opposition effect on endometrium from dysfunctional oestrogen-progesterone imbalance +/- dysfunctional progesterone-mediated cellular Tissue inhibitors to- and matrix metallopeptidases (TIMP/MMP) – has been associated with HMB, ectopic gestations, miscarriages and secondary postpartum haemorrhage. Our case had no preceding significant risk factors and inadequate sonographic-evidence- a common occurrence in literature. This led to diagnostic and management challenges, increasing anxiety and treatment morbidity. Management in young women should be expectant +/- hormonal treatment. Reassurance with individualised progestogens type and dose will aid contraceptive-compliance. Conclusion While endometrial/decidual cast is not associated with a deleterious health effect, it can be distressing to patients and a diagnostic challenge to clinicians, unfamiliar with it. More research into underpinning pathways and disease associations is needed.

A Case Report: MRI versus Ultrasonography in Abdominal Pregnancy, Which One is Better?

Abdominal pregnancy is a rare potentially life-threatening form of ectopic pregnancy. First trimester sonography is very useful to identify an abdominal pregnancy earlier. However, cases of undiagnosed abdominal pregnancy at second and third trimesters are still reported in obstetric practice. Abdominal pregnancy is often missed during routine ultrasound examination that has classical findings such as the absence of myometrial tissue between the maternal bladder and the pregnancy, an empty uterus, poor visualization of the placenta, oligohydramnios, and abnormality of fetal lie. Magnetic Resonance Imaging (MRI) has been reported as the best abdominal pregnancy detection modality in a later gestational age due to its ability in detailing vascular and placental organ invasion. The reporting of a case of a patient with an abdominal pregnancy involves a diagnosis using abdominal ultrasound in the second trimester. A 38-year-old woman was admitted to RSUP Dr. Hasan Sadikin Bandung with suspected abdominal pregnancy at gestational age of 28 weeks. Due to unclear clinical manifestation, the diagnosis of abdominal pregnancy was not detected and there was a plan for vaginal termination of pregnancy by misoprostol induction in the hospital before. The patient complained about progressive abdominal pain and difficult of defecation for 2 months before and this condition worsened in the last 4 days. Ultrasound examination in RSHS revealed that there were one living fetus, extra-uterine pregnancy with estimated fetal weight of 664 grams, fetal heart rate (+), and transverse breech presentation. Congenital abnormality was difficult to assess due to oligohydramnios. MRI was performed and showed intra-abdomen pregnancy with one living fetus, breech presentation, and intact amniotic membrane with oligohydramnios which was superior to the uterus and attached along the anterior aspect of uterus. The placenta had the size os 11.52 x 7.02 x 13.07 cm, was diffusely heterogenous in shape, on the right superoanterolateral wall of the gestational sac, and seemed to be attached to the right anterior abdominal wall and part of the intestine in the superior part while no placental adherence was seen. The patient was successfully treated with exploratory laparotomy with complete removal of the fetus and placenta. This case was reported to compare the advantage of MRI and ultrasound examination in detecting abdominal pregnancy, especially in late gestational age.

A Rare Case Report of Caesarean Scar Ectopic Pregnancy

Caesarean scar pregnancy is rarest pregnancy, increasing incidence due to increasing in number of caesarean deliveries. It is defined as blastocyst implants on a previous caesarean scar Herman A. Early diagnosis can be done by using ultrasound with empty uterus and cervix, mass in the anterior wall of uterus in scar area. Early diagnosis leads to prompt management and improves the outcome by allowing preservation of future fertility and decreases maternal morbidity and mortality, this is possible with ultrasound imaging. When ultrasound is inconclusive or equivocal then MRI has important role in diagnosis before therapy or intervention. Here we are presenting a case of G11P2+(1)L2A7 with previous two caesarean deliveries, diagnosed as caesarean scar ectopic pregnancy with the help of sonography. Patient underwent laparotomy and on histopathology report, caesarean scar pregnancy was confirmed.

Abstract #1404395: Metastatic Choriocarcinoma: A Rare Cause of Thyrotoxicosis

Although Graves’ disease continues to be considered the most frequent cause of clinical hyperthyroidism in pregnancy, the disproportionately high production of human chorionic gonadotropin (HCG) as occurs in gestational trophoblastic disease (TSG), is another possible cause that should be considered when evaluating thyrotoxicosis in pregnancy. A 19-year-old female with unremarkable past medical history who was admitted for nausea, vomiting and abdominal pain for 2 weeks. Her last period was 4 weeks prior to her presentation and patient denied any vaginal bleeding. Her period had been irregular since her last miscarriage a year earlier. She denied being sick recently, and her last flulike illness was 4 months ago. Denied using any medication at home including herbal medication or OCPs. Review of systems was significant for fatigue, heat intolerance, palpitation, tremor, loss of appetite and unintentional weight loss over the last week. She denied diarrhea or anxiety. On presentation, Patient was hypotensive 90s/40s mmHg and tachycardic 140s bmp. EKG showed sinus tachycardia. Initial work-up was significant for HB 6.2, WBC 11.6 and B-hCG 9678 IU/ml. Liver enzymes were elevated. Transvaginal ultrasound showed empty uterus. Pan CT showed hemoperitonium and liver, lung and kidney lesions concerning for metastatic choriocarcinoma which was confirmed with positive liver biopsy. Work-up also showed suppressed TSH 0.01uIU/ml, high free T4 2.54ng/dl, and high free T3 5.1ng/dl, absent TSI, normal Tg level with negative Tg antibodies. There was no baseline TSH to compare. BHCG with dilution was 5,430,055IU/ml. Thyroid ultrasound was normal. Patient was diagnosed with metastatic choriocarcinoma and treated with 3 cycles of cisplatin/etoposide chemotherapy. Patient did not receive any antithyroid medication due to elevated liver enzymes and mild symptoms. B-HBG following the treatment was 3mIU/ml, TSH was 1.5 uIU/ml and FT4 was 1.1ng/dl. Hyperthyroidism has been reported in many patients with GTD. The beta subunit of β-hCG is structurally similar to TSH, allowing it to bind to the TSH receptor on thyroid follicular cells. It has been reported that β-hCG levels of greater than 200,000 m[IU]/ml sustained for several weeks are required to induce clinical hyperthyroidism. It is estimated that for every 10,000 m[lU]/ml increase in serum hCG, TSH decreases by 0.1 mlU/ml and free T4 increases by 0.1 ng/dL. No clear risk factors for hyperthyroidism in GTD were identified. Presentations can range from subclinical hyperthyroidism to thyrotoxicosis and thyroid storm. This case was challenging because the initial B-HCG was not high enough to cause thyrotoxicosis but delusional B-HCG confirmed our suspicion. While hyperthyroidism can be definitively managed with surgical evacuation of the uterus in GTD, hyperthyroidism secondary to metastatic choriocarcinoma could be successfully treated with chemotherapy with or without antithyroid medication. The increase in TSH usually parallel the reduction in BHCG.

Advanced tubal pregnancy at 34 weeks with eclampsia and HELLP syndrome: a case report and literature re

BackgroundTubal ectopic pregnancies in the late stages of pregnancy are uncommon, and reports on their complications are scarce. We present the case of a woman who had a tubal ectopic pregnancy at around 34 weeks and developed severe pre-eclampsia complications.CaseA 27-year-old woman presented to our hospital several times with vomiting and convulsions. A physical exam revealed hypertension, scattered ecchymosis, and a large abdominal mass. A computed tomography (CT) scan performed in an emergency revealed an empty uterus, a stillbirth baby in the abdominal cavity, and a crescent-shaped placenta. Blood tests revealed that the patient had a low platelet count and clotting dysfunction. Laparotomy confirmed advanced right fallopian tube pregnancy without rupture, and salpingectomy was performed. Pathological examination revealed a significantly thickened tubal wall, adhesion of the placenta, and poor placental perfusion.ConclusionThe unusually thickened muscular layer of the tube may be one of the reasons for tubal pregnancy progressing to an advanced stage. Placenta adhesion and the special site to which it is attached reduce the risk of rupture. The detection of a crescent-shaped placenta on imaging may aid in the accurate diagnosis, distinguishing between abdominal and tubal pregnancy. Women with advanced ectopic pregnancy are more likely to develop pre-eclampsia and have poorer maternal-fetal outcomes. These negative outcomes may be influenced by abnormal artery remodeling, villous dysplasia, and placental infarction.

Ovarian Pregnancy: 2 Case Reports and a Systematic Review.

Ovarian pregnancy is a rare but well-known pathology. However, pathophysiology, diagnosis and treatment are not established. Therefore, all case reports on ovarian pregnancy published in PubMed from November 2011 till November 2022 were reviewed and two case reports were added. In these 84 case reports, 8% of ovarian pregnancies occurred in women without or with blocked oviducts and 23% were localised on the other side than the corpus luteum. Since symptoms are not specific, ovarian pregnancy has to be suspected in all women with abdominal bleeding. Surgical excision is the preferred treatment. However, since an associated intra-uterine pregnancy cannot be excluded, care should be taken not to interrupt this intra-uterine pregnancy with the uterine cannula or by damaging the corpus luteum. In conclusion, in women with abdominal bleeding, an ovarian pregnancy cannot be excluded, even in women with a negative pregnancy test or an empty uterus on transvaginal ultrasonography. Therefore, a laparoscopy is indicated but the surgeon should realise that an associated intra-uterine pregnancy also cannot be excluded and that therefore care should be taken not to interrupt this intra-uterine pregnancy by the uterine cannula or by damaging the corpus luteum.

A Curious Case of Misapprehension – Dermoid Cyst Masquerading as a Ruptured Ectopic Pregnancy

We discuss the case of a 26-year-old woman who presented with pelvic pain and recent onset vaginal bleeding in early pregnancy. Transvaginal USS identified significant free fluid in the pelvis associated with a right adnexal mass and an empty uterus. A ruptured ectopic pregnancy was suspected, and the patient was taken to theatre for an emergency laparoscopy. Paradoxically, the procedure found no signs of intra-abdominal blood loss. Instead, a large, unruptured 20cm ovarian cyst filled the right adnexa and Pouch Of Douglas (POD), extending posteriorly towards the pelvic brim. It was a right Ovarian, Dermoid cyst. Surprisingly, the dilemma is not unique. We identified similar reports in the literature where unsuspected ovarian pathology is discovered at the time of early pregnancy surveillance, often masquerading as an acute complication of early pregnancy. In this report, the patient went on to have a spontaneous miscarriage, and the cyst was later removed by mini- laparotomy. We present this case as an opportunity to highlight the epidemiology of adnexal pathology presenting for the first time in early pregnancy and to help broaden clinical suspicion when considering potential diagnoses at the time of presentation.

Abdominal Pregnancy with Hemorrhagic Placenta: About a Case at the Mother and Child Health Center of Zinder

Background: In developing countries maternal mortality and morbidity are most often due to the late to consult, poverty and ignorance. Added to this is, the under-medicalization of the health system. The objective of study is to report a case of late consultation and its consequences and make recommendations to improve: case of abdominal pregnancy with hemorrhagic placenta at the Health and Mother Center (CSME) in Zinder/Niger. Clinical Observation: We describe a case of abdominal pregnancy with hemorrhagic placenta in a 24-year-old woman, without profession, resident in the city of Zinder with a low economic level, consulted for abdomino-pelvic pain. She had a notion of amenorrhea for 5 months without any consultation made. She was pale, feverish and had abdominal pain. Ultrasound revealed a 23-week-old fetus and an empty uterus. The diagnosis was abdominal pregnancy. A laparotomy was performed and a The morbidity was hysterectomy and anemia. The postoperative period course was complicated with anemia. The patient was cured on the 9th day with a good vital prognosis. Conclusion: Abdominal pregnancy occurred in a patient who presented a risk factor. Ultrasound was the key diagnostic test. Surgery was the treatment of choice and the prognosis depends on the earliness of the consultation. Community awareness and early consultation with health services can improve the prognosis of abdominal pregnancy.

Chronic Ectopic Pregnancy Masquerading as Ovarian Cystadenoma: A Case Report

The term ‘chronic ectopic pregnancy’ refers to a type of tubal pregnancy in which a pelvic mass frequently develops as a result of repeated small ectopic ruptures or abortions, rather than a single episode of bleeding. Chronic ectopic pregnancy can often present with vague symptoms, making it susceptible to misdiagnosis and delaying treatment. In this case, a 27-year-old woman with para 2 and 2 live births presented with complaints of on-and-off abdominal pain in the right inguinal region for the past two months. During the clinical examination, a substantial, firm mass measuring 6×6 cm was palpated in the right adnexal region, not associated with any adnexal tenderness. Transabdominal sonography suggested an empty uterus with a solid cystic mass, round/ oval in shape, located in the right adnexal region measuring approximately 6.9×6.4 cm. The ultrasound findings in these patients can either show an amorphous, avascular mass or a highly vascular complex. The diagnosis can be mistaken for endometriosis, acute pelvic inflammatory illness, vascular tumours, pelvic abscess, or, in this instance, a cystadenoma. In most cases, radiologic findings are essential in the differential diagnosis, but it is mostly confirmed through surgery, as in this case. A laparotomy was performed, which revealed a chronic ectopic pregnancy, and a salpingo-oophrectomy was performed.

کتاب وسنت سے قرائن کی حجیت کے دلائل کا جا ئزہ

Circumstantial evidence holds great importance in this age. Islam too, has given special importance to circumstantial evidence. If no evidence is found, the decision can be made in the light of circumstantial evidence if the case is not related to, Hadood and Qisas. Sometime circumstantial evidence supports and strengthens other available evidence.Since Quran & Sunnah have not denied the circumstantial evidence and its authenticity exists in our Sharia also .Trust in circumstantial evidence and apparent marks is obligatory because it ensure Justice to the victim, and the orders or not delayed and people get their rights in this regard the example of Holy Prophet (SAW) is enough when he said emergence of the menstruation blood is the symbol of an empty uterus and that woman is impregnate this commandment has been described as the end of iddat duration. The sexual intercourse has also been made forbidden and after that wedlock has been declared lawful .This is the best proof to justify circumstantial evidence and a clear example of action based on circumstantial evidence.

Uterine didelphys: A Case report of successful term pregnancies in each endometrial cavity

Background: Uterine didelphys is a rare congenital anomaly that may increase the risk of pregnancy loss and adverse perinatal outcome. There is limited knowledge of specific increased risk related to uterine didelphys. Uterine didelphys occurs in approximately 1 in 3000 women and accounts for 8 -10% of all mullerian duct anomalies (MDAs). Aim: To present this rare congenital clinical condition and offer management modality experience from the Rivers State University Teaching Hospital (RSUTH). Case report: Mrs. MC was a 33 year old booked G3 Para 1+ 1 (alive), previous caesarean section, who presented for antenatal care. Her index pregnancy was complicated by premature uterine contractions and ante – partum haemorrhage at 29 weeks and 30 weeks gestation respectively which were managed successfully. Obstetric ultrasound scan revealed a second uterine cavity with separate endometrial plate in keeping with uterine didelphys. She subsequently had an elective repeat caesarean section at 38 weeks gestation for transverse lie and uterine anomaly. Findings were a gravid left uterus and an empty right uterus with a lower segment scar. The left uterus contained a live male neonate in transverse lie with a birth weight of 3.5 kg and good Apgar scores. The baby was successfully managed for neonatal Jaundice. The mother developed postpartum haemorrhage which was successfully managed. The mother and baby were discharged on the 5th and 12th post-operative day respectively in good clinical state. The mother was given appointment to the family planning clinic. Conclusion: We presented a patient with a rare congenital clinical condition – uterine didelphys who conceived spontaneously. She had a previous successful pregnancy on the right uterus followed by a spontaneous miscarriage and successfully carried the index pregnancy on the left uterus to term and was delivered by an elective repeat caesarean section with good fetal and maternal outcome.

Frequency of outcomes of patients with pregnancy of unknown location at a tertiary care hospital.

Background: A pregnancy of unknown location (PUL) is said to occur when empty uterus is seen on a Transvaginal Scan in a female with a positive pregnancy test with absence of signs of an intrauterine pregnancy (IUP) or an ectopic pregnancy. Aim: To determine the frequency of outcomes of patients with pregnancy of unknown location at a tertiary care hospital. Methods: The study was carried out at Department of Obstetrics &Gynecology, Lady Willingdon hospital, Lahore. It was a Descriptive case series conducted from 2021 to May 2022. 160 subjects meeting the inclusion criteria were enrolled in the study. A thorough history was obtained and levels of serum Beta-HCG recorded. Serum beta HCG levels of 25IU/L represented a positive pregnancy test. The follow up consisted of monitoring serum beta HCG levels after 48 hours and evaluation of findings of transvaginal ultrasound. The females were followed till they were placed in the category of failing PUL, an intrauterine pregnancy or an ectopic pregnancy. Data was collected from women categorized as having a PUL. Results: In this trial, of 160 cases, it was seen that 109(68.13%) had amenorrhea whereas 51(31.87%) had bleeding at the time of presentation. Frequency of outcomes of patients with pregnancy of unknown location showed that 75(46.88%) had failing PUL, 19(11.87%) had ectopic pregnancy, 15(9.38%) had persistent PUL and 51(31.87%) had intrauterine pregnancy. Conclusion: Failing PUL was the leading entity in cases of pregnancy of s unknown location followed by ectopic pregnancy and persistent PUL. However, this data is primary and needs validation through some other local trials. Keywords: Pregnancy of unknown location, outcome, failing PUL, ectopic pregnancy, persistent PUL

Rare abnormal pregnancy implantation: A case report of 39 year old G2P1 with cervical ectopic gestation

The case is that of a 39 year old G2P 1, 1 alive who presented with recurrent bleeding per vagina following 8weeks amenorrhea, Pregnancy confirmed with urine test. She was married and no attempts at termination of pregnancy. Ultrasound scan revealed empty uterus without any adnexea mass but a gestational sac in the cervical canal with an active fetus and vascular flow on Doppler colour interrogation. A diagnosis of cervical ectopic pregnancy was made and she had medical management with initial mifepristone and then intramuscular methotrexate. A subsequent gentle evacuation of the cervical canal was done and trans-cervical catheter inserted for 2 weeks to prevent cervical adhesion. Urine Pregnancy test done after 3 weeks was negative. Conclusion: Cervical ectopic pregnancy is one of the very rare forms of pregnancy implantation that can be associated with devastating outcome but prompt diagnosis and management help improve patient’s prognosis.

A rare case report of bilateral ruptured tubal ectopic pregnancy

Implantation of the fertilized ovum outside the uterine cavity is called ectopic gestation. The common presenting symptoms are per vaginal bleeding till 12 weeks, pain in the lower abdomen, and absence of menses. ß-HCG level is increased (>1000IU/L) and transvaginal ultrasonography shows an empty uterus. These findings essentially confirm the diagnosis. In this, we have a 23-year-old, G2P1L1 with a history of 3 months of amenorrhea, presenting to the labor ward with a history of per vaginal bleeding and lower abdominal pain. The diagnosis was 10 weeks right-sided ruptured ectopic pregnancy and intraoperatively found to be ruptured ectopic pregnancy in both fallopian tubes which we managed successfully by performing emergency laparotomy with bilateral partial salpingectomy.

A Retroperitoneal Perivascular Ectopic Pregnancy Case: Diagnosis and Possible Lymphatic Migration

A pregnant 30-year-old gravida 5, para 2 (2 cesarean sections and 2 medical abortions) woman presented with a serum beta-human chorionic gonadotropin (β-hCG) level of 11 141 IU/L on the 47th day after her last menstrual period. Transvaginal sonography showed an empty uterus, and a curettage and laparoscopic exploration were nondiagnostic. Subsequently, her plasma β-hCG level rose to 17 351 IU/L. An abdominal computed tomography (CT) demonstrated a 2.2-cm pregnancy sac located on the surface of the inferior vena cava near the fourth lumbar vertebrae (Fig.

Multiple uterine perforations during manual vacuum aspiration: the need to increase the clinical awareness of attending healthcare professionals.

The risk of uterine perforation during manual vacuum aspiration (MVA) is reduced by using Karman cannula (which has a rounded tip) during the procedure. A 35-year-old multigravida at 13 gestational weeks presented with vaginal bleeding of a day duration and ultrasound evidence of retained products of conception suggestive of incomplete miscarriage. The patient was rhesus D positive and stable. She had MVA which was performed using Karman cannula, and developed severe vaginal bleeding. The differential diagnoses were incomplete uterine evacuation and uterine perforation. During a laparotomy in Lloyd-Davies position, haemoperitoneum and six uterine perforations on the anterior and fundal parts, each approximately 5 mm in length (Figure 1), were found. The perforations were repaired and a check uterine curettage under oxytocic cover showed an empty uterus. The abdominal cavity was washed and closed. She was transfused three units of red blood cell concentrate and had a normal six weeks follow-up. When an instrument inserted into the uterus is pushed beyond the estimated depth of the uterus, a perforation must be suspected and the condition may be managed conservatively. A surgical procedure complicated by surgeon's loss of perception (in this case tactile) of tissues' anatomy is hazardous.

Laparoscopic Removal of an Abdominal Ectopic Pregnancy Requiring Partial Cecectomy

A 37-year-old gravida 3, para 1011 presented with abdominal pain and lightheadedness. Her serum human chorionic gonadotropin concentration was 15 917 U/mL. On examination, her abdomen was tender with positive peritoneal signs. Transvaginal ultrasound showed an empty uterus with blood in the pelvis concerning for ectopic pregnancy. The patient was transfused 1 unit of packed red blood cells and brought to the operating room for diagnostic laparoscopy. Upon intubation, the patient was hypotensive so a massive transfusion protocol was initiated.