Severe Vaginal Bleeding Research Articles

Case Report: Spontaneous cornual Pregnancy at 7 Weeks: A Gynecological challenge

Introduction and Importance Cornual pregnancy (CP) is a rare and dangerous type of ectopic pregnancy, occurring in 2% to 4% of cases. Due to its atypical location in the uterine horn, it poses a high risk for severe complications, such as rupture of the uterus, and life-threatening bleeding, particularly when diagnosis is delayed. Case Presentation We report the case of a 35-year-old female patient presenting with severe pelvic pain and vaginal bleeding, with 12 weeks of amenorrhea. Clinical evaluation revealed elevated β-HCG levels and transvaginal ultrasound showed a 7-week unruptured right cornual pregnancy. Surgical management involved a mini-laparotomy, which confirmed the diagnosis and a cornuostomy along with a right salpingectomy was performed. The patient’s postoperative course was uneventful, and follow-up confirmed complete recovery. Clinical Discussion Cornual pregnancies, though rare, carry a significant risk of serious complications and maternal death due to delayed diagnosis. Risk factors encompass a history of miscarriage, elective abortion, sexually transmitted infections, and smoking, all contributing to abnormal implantation. Early diagnosis is challenging but crucial, with ultrasound being key for detection. Management depends on gestational age, patient stability, and future reproductive plans, with methotrexate or surgical intervention being standard options. Conclusion Cornual pregnancy, despite its rarity, demands prompt and accurate diagnosis to prevent catastrophic outcomes. This case underscores the need for individualized treatment strategies and highlights the importance of early intervention. Ongoing research is vital to improving diagnostic approaches and therapeutic outcomes.

Postmenopausal Vaginal Bleeding Due to Vaginal Leech Infestation: A Case Report

Introduction: Vaginal bleeding due to leech bites is a highly unusual and serious problem in postmenopausal women, potentially leading to severe complications and even death. Case Presentation: A 68-year-old rural woman, 13 years post-menopause, was admitted to a hospital in eastern Iran with a complaint of continuous vaginal bleeding with clot discharge for 12 days. During the medical examination, a dark worm moving in waves was observed in the labia minora of the vulva. The area was washed with 0.9% normal saline solution, and the leech was removed from the inner surface of the labia minora using forceps and pincers. The patient was monitored as an outpatient for 4 hours to control the bleeding and was subsequently discharged in good condition. She was advised to take iron tablets and folic acid for one month. Her test results were as follows: hemoglobin = 10 mg/dL, hematocrit = 32%, platelet count = 145,000, prothrombin time = 13 seconds, partial thromboplastin time = 35 seconds, and INR = 1.1. Her vital signs at admission were: temperature = 37.5°C, pulse rate = 100/min, blood pressure = 120/60 mmHg, and respiratory rate = 30 breaths per minute. Conclusions: Vulvar and vaginal leech bites can cause severe vaginal bleeding and anemia in postmenopausal women. To reduce complications caused by delays in diagnosis or treatment, healthcare workers should consider the possibility of vulvar and vaginal leech bites in postmenopausal rural women and individuals who use river water for drinking, bathing, or showering. Taking a detailed history and performing a thorough physical examination before any diagnostic procedure can help quickly and accurately diagnose the cause of bleeding in these patients.

Cervical fibroid: A diagnostic dilemma and operative challenge – one year study

: Cervical fibroids are very rare, with varying clinical presentations, and account for only 1–2% of cases. Cervical fibroids are enigmatic as they present with varying symptoms and simulate several clinical entities, for instance, a large cervical polyp, incarcerated procidentia, chronic uterine inversion, and the Ca cervix. : A two-year retrospective analysis of women diagnosed with cervical leiomyoma was conducted at Obstetrics and Gynaecology department, PGIMS Rohtak (a tertiary care institute in Northern India). A total of 24 cases diagnosed with cervical fibroid (CF) were studied. 75% of the females had vaginal bleeding, 44.6% had heavy menstrual bleeding, 33.3% had irregular bleeding, and one had postmenopausal bleeding. 41.6% had urinary symptoms; 1.5% complained of vaginal discharge; difficulty in stools (16.6%); and leiomyosarcoma (8.3%). We cannot find a clear demarcation of presenting symptoms between anterior and posterior fibroid. It was discovered that the development of malignancy and bladder and intestinal problems was linked to an increase in CF mass, while severe anaemia and vaginal bleeding were not. A cervical fibroid is mostly benign, can be present at extremes of age, and its atypical presenting symptoms pose difficulty in diagnosis. Vaginal bleeding and retention of urine are the most common symptoms. Central and supravaginal fibroids are difficult to operate. Proper pre-operative delineation of altered anatomical structure are essential for choosing the correct modality of treatment. In large cervical fibroids, suspected malignancy before surgery and hidden cervical malignancy can coexist.

Uterine artery pseudoaneurysm presenting with subcutaneous hematoma and vaginal bleeding following cesarean delivery

We present a rare case of uterine artery pseudoaneurysm (UAP) following an emergency cesarean section, which led to severe vaginal bleeding and subcutaneous hematoma. The patient, a 40-year-old woman with no history of hemophilia or hemostasis disorders, presented with sudden profuse vaginal bleeding and multiple subcutaneous hematomas at the site of the cesarean scar ten days postoperation. Ultrasound and CT scan confirmed the presence of a pseudoaneurysm in the right uterine artery. Due to the unavailability of radiological embolization, surgical ligation of the right internal iliac artery was performed. Postoperative follow-up showed successful resolution of the pseudoaneurysm and cessation of bleeding. This case highlights the importance of considering UAP in the differential diagnosis of postpartum hemorrhage and demonstrates the efficacy of surgical intervention when embolization is not available.

Double bad luck: pulmonary embolism and vaginal bleeding - a case report

BackgroundPulmonary embolism is a common and potentially fatal condition. Exogenous estrogens in contraceptives are associated with an increased risk of venous thrombo-embolism. However, discontinuation of a combined oral contraceptive can lead to severe withdrawal bleeding in an anticoagulated patient.Case presentationWe report a case of a 47-year-old female who presented to the emergency room with a two-day history of worsening shortness of breath and chest pain. Her chronic medication included a combined oral contraceptive pill. Transthoracic echocardiogram showed pulmonary hypertension and right ventricular dilatation. Computerized tomography scan revealed bilateral pulmonary embolism. She received thrombolysis with alteplase and was started on rivaroxaban. Five days after discharge, however, she was readmitted with severe vaginal bleeding.Discussion and conclusionWe describe a case of submassive pulmonary embolism, treated with thrombolysis and anticoagulation, who developed severe vaginal bleeding after stopping the contraceptive pill. This case highlights the importance of detailed menstrual history taking when initiating anticoagulation in women. Discontinuation of oral contraceptives, while important in reducing the risk of recurrent thrombosis, could be postponed until the end of the recommended course of anticoagulation and until a safe alternative form of contraception has been established, if required.

Post molar choriocarcinoma with solitary renal metastasis in the absence of primary uterine tumor: a case report and review of the literature

BackgroundChoriocarcinoma is a rare and highly malignant form of gestational trophoblastic disease that may develop following pregnancy, abortion, or a hydatiform mole. Renal metastatic involvement by post molar choriocarcinoma is even rarer. In this case report, we describe a unique case of post molar choriocarcinoma with a solitary renal metastasis in the absence of a primary uterine tumor and metastases in other sites, which presented with urological symptoms and spontaneous renal hemorrhage.Case presentationA 41-year-old Persian woman with history of complete hydatiform mole presented with severe flank pain, nausea, vomiting, gross hematuria, and vaginal bleeding. Laboratory tests demonstrated a serum beta human chorionic gonadotropin hormone level of 60,000 mIU/mL. Imaging studies showed a lesion at the lower pole of the left kidney with active bleeding surrounded by hematoma, as well as an empty uterine cavity. Additionally, bilateral pleural effusion was detected without any lesion within the lungs. Subsequently, the patient underwent laparotomy, partial nephrectomy, and left para-ovarian cystectomy. Endometrial curettage was also carried out. The histopathology report revealed choriocarcinoma renal metastasis with high expression of beta human chorionic gonadotropin, cytokeratin 7, and Ki 67. Moreover, there were no malignant cells in the endometrial curettage specimens, and a corpus luteum cyst was found within the para-ovarian cyst. Further investigations revealed that the pleural effusion was free of malignant cells, and there was no evidence of metastatic lesions in the brain. As a result, the patient was referred to the oncology department to receive chemotherapy, and the beta human chorionic gonadotropin levels dropped to 5 mIU/mL after receiving courses of a standard regimen of etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine/oncovin over 3 weeks. Finally, monthly measurements of beta human chorionic gonadotropin levels for 6 months indicated that levels have constantly remained within normal ranges, showing no evidence of recurrence or new metastasis.ConclusionsUrological symptoms such as hematuria or spontaneous renal hemorrhage might be the only presentation of post molar choriocarcinoma with renal involvement. Thus, it can be beneficial to measure serum beta human chorionic gonadotropin levels among females of childbearing age who present with unexplained urological symptoms, especially if there is a history of prior hydatiform mole.

Presentation Invasive Mole After Normal Pregnancy: A Very Rare Case Report

Gestational trophoblastic neoplasia (GTN) is a rare neoplasm and is a spectrum of proliferative disorders of placenta. Invasive mole is a subtype of GTN that almost always arises after molar pregnancy. This report presents a 35-year-old woman with an atypical presentation of invasive mole after a normal pregnancy. The patient presented with a complaint of vaginal bleeding after normal vaginal delivery. Invasive mole was diagnosed based on findings of imaging and elevated beta human chorionic gonadotropin (ß-hCG) levels. Hysterectomy was finally decided upon due to severe vaginal bleeding and the patient’s request. Although GTN occurs after normal delivery, the patient recovered without receiving chemotherapy. It is important to consider all subtypes of GTN as a differential diagnosis of patients with abnormal postpartum bleeding and elevated ß-hCG levels even after a normal pregnancy.

Pregnancy and Delivery Outcome Among Ladies with Glanzmann Thrombasthenia: A Report from Glanzmann Thrombasthenia Registry of Al-Madinah, Saudi Arabia

Introduction Glanzmann's thrombasthenia (GT) is an autosomal recessive bleeding disorder due to functional platelet defects impairing platelet aggregation. AlMadinah has reported the highest prevalence of GT globally, with a prevalence of 1:10,000. Pregnancy had been reported among ladies with GT with different outcomes. As a bleeding disorder, Pregnancy among ladies with GT carries a higher risk for bleeding either during pregnancy or intra and postpartum. Neonates have an increased risk for hemorrhage, either due to alloimmunization or they may carry the gene of GT. Many GT ladies got pregnant earlier when GT diagnosis was difficult, and they did not know their diagnosis; even after the diagnosis was possible, ceasing the menstrual cycle was not culturally acceptable. In this study, we are describing the pregnancies among GT ladies and their outcomes. Methods This is a report from the AlMadinah GT registry in the Madinah Hemophilia Comprehensive Care Center. The registry covers a period of 20 years and includes all patients with a confirmed diagnosis of GT. 136 GT patients were identified. 11 patients had no data available. A spreadsheet designed to collect detailed data about pregnancy, delivery, and neonates. Electronic and hard copy medical records have been accessed to collect data. Data was analyzed by the statistical package of social sciences (SPSS) version 23. The research and ethical committee approved the study. Results Twenty-eight pregnancies have been identified. The median age of mothers at the time of pregnancy was 30 ± 5.7 years (20 - 42 years). Mothers' Gravidity was 1-7 (median 2.5 ± 1.6), and parity was 1-6 (median 2 ±1.4). Five miscarriages (18%) identified occurred at the 17 th, 11 th, 13 th and 15 th gestational weeks. In contrast, 5 th one is not on record. Three miscarriages took place after moderate to severe vaginal bleeding. Mild to severe post-abortion bleeding was controlled with platelets transfusion, activated human recombinant factor 7 (rFVIIa), and tranexamic acid. Thirty-two bleeding episodes occurred during 16 pregnancies, with 1-5 bleeding episodes per pregnancy (Median of 2 episodes). Seven (22%) bleeding episodes were vaginal bleeds, while 25 (78%) were GT-related bleeds such as gum bleeding or epistaxis. Two patients must undergo plasma exchange and be on steroids due to alloimmunization development during pregnancy. Delivery occurred at the gestational age of 34-40 weeks (median 38 ± 2 weeks). Sixteen (70%) deliveries were vaginal, and 7(30%) were cesarean sections. The indications for cesarean sections were family request in 4 cases, fetal distress in two instances, and precautional section in one case. Prophylactic platelets transfusion had given pre-delivery on four occasions, rFVIIa on 4, and a combination of rFVIIa and platelets transfusion on six occasions. Tranexamic acid was used in all cases. Ten deliveries were conducted with no prophylaxis. Post-partum hemorrhage (PPH) occurred in 18 (64%) cases, 13 (72%) cases of primary PPH, and 5 (28%) cases of secondary PPH. We could not find a correlation between pre-delivery prophylaxes and PPH (P=0.2). PPH had controlled successfully with platelets transfusion and rFVIIa though red blood cell transfusion was needed on eight occasions. Twenty-eight pregnancies produced 24 babies (13 girls and 11 boys). Four babies had bleeding (2 intracranial hemorrhages, one subdural hematoma, and one gum oozing), and 9 had alloimmunization with mild to severe thrombocytopenia. Of all babies tested for GT, 6 of them were GT. Conclusions Pregnancy among ladies with GT carries a higher risk of bleeding. Management of pregnancy in women with GT has to be in a Multidisciplinary approach. The high rate of PPH among GT ladies makes it essential to treat it promptly. Pregnancy among ladies with GT should be studied in multi-centers sitting to learn more about clinical courses and management.

Factors associated with the knowledge of obstetric danger signs among pregnant women attending primary health care antenatal care clinics in Abha city.

Knowledge of obstetric danger signs would equip women to make the right decisions and appropriate actions timely to have better health care assistance which will impose a significant impact on maternal mortality and morbidity. Hence, this study aimed to know the factors associated with the knowledge of obstetric danger signs among pregnant women who attend the primary health care clinics, which is considered as the first gate to seek health care for pregnant women during antenatal checkups. This is a cross-sectional study conducted among 400 pregnant women selected by simple random sampling technique who were attending antenatal clinics at primary health care centers at Abha City by using an interview-based questionnaire.cores of <50%, 50-75%, and >75% were considered to be poor, intermediate, and good scores. Frequencies and percentages were used for descriptive variables, whereas for association, tests of significance (Chi square, t-test, and F-test) were applied. Almost 70.8% of participants received health information on obstetric danger signs. The main sources of information were the Internet (23%), family, relatives or friends (17%), and health care providers. The highest participants' correct responses regarding obstetric danger signs were related to severe vaginal bleeding (93.5%), convulsions (76.8%), and decreased fetal movements (76.5%). Proportions of participants with poor knowledge showed an inverse and significant increase with their educational levels (P < 0.001). The highest percentage of poor knowledge grade was observed among participants with no children (54.6%). Participants who received previous information on danger signs had significantly better knowledge grades than those who have not received previous information (P < 0.001). Women's knowledge was suboptimal regarding obstetric danger signs. 30% of women did not receive information about danger signs. Health education provided on obstetric danger signs to pregnant women should be enforced to those who are illiterate, are unemployed, have a low family income, and are with no or less previous pregnancies.

Knowledge of Obstetric Danger Signs among Pregnant Women in the Eastern Democratic Republic of the Congo.

A lack of awareness regarding obstetric danger signs (ODS) is one of the factors that delay a pregnant woman's decision to seek emergency obstetric care. In developing countries, this delay can lead to high morbidity and mortality among pregnant women. In eastern Democratic Republic of Congo (DRC), very few studies have been conducted to assess the level of knowledge of pregnant women about ODS. Therefore, this study aimed to assess the knowledge of pregnant women about ODS in health facilities in eastern DRC. This quantitative cross-sectional, descriptive, and analytical study was conducted in 19 health facilities in the Kasongo health zone in the south Maniema Province of eastern DRC. A total of 624 pregnant women aged 12-49 years were interviewed in this study. Of these, 60.6% were secondary school graduates, >99% were married, 85.5% were cultivators, and 67.9% were Muslims. The knowledge of ODS among pregnant women was low (21.9%). The most cited danger signs during pregnancy, labor/delivery, and postpartum included severe abdominal pain and severe vaginal bleeding. Additionally, pregnant women aged 30-39 years (p = 0.015) and those who had given birth once (p = 0.049), twice (p = 0.003), 3-5 times (p = 0.004), and >5 times (p = 0.009) were more likely to be aware of ODS than others. Our findings indicated that pregnant women have little knowledge of ODS, which makes it difficult for them to take prompt decisions to seek emergency obstetric care. Thus, strategies to increase the knowledge of pregnant women about obstetrical danger signs by healthcare providers during prenatal consultations (antenatal care) must be developed to improve their rapid decision-making skills during pregnancy, labor, and postpartum.

Knowledge of danger signs in pregnancy and their associated factors among pregnant women in Hosanna Town, Hadiya Zone, southern Ethiopia.

Danger signs in pregnancy can warn of maternal health problems. In developing African countries, including Ethiopia, the rate of maternal mortality is high. There is little knowledge of danger signs during pregnancy and their associated factors at the community level in the study area. A community-based, cross-sectional study was conducted to assess knowledge about danger signs among pregnant women in Hosanna Zuria Kebeles between 30 June and 30 July 2021. A simple random sampling method was used to select eligible pregnant women. The sample size was proportionally allocated based on the number of pregnant women in each kebele. Data were collected in face-to-face interviews using a pretested questionnaire. The descriptive results were presented as proportions, whereas the analytic results were presented as adjusted odds ratios (AOR). The prevalence of good knowledge of danger signs in pregnancy was 259/410 (63.2%, 95% confidence interval (CI) 58.3-67.8). The most common known danger signs during pregnancy were severe vaginal bleeding (n = 227, 55.4%), followed by blurred vision (n = 224, 54.6%). In the multivariable analysis, the age of the respondent (AOR = 3.29, 95% CI 1.15-9.38), the tertiary education of the mother (AOR = 5.40, 95% CI 2.56-11.34), and the number of live births (AOR = 3.95, 95% CI 2.08-7.48) were statistically significant factors. There was an adequate prevalence of knowledge of danger signs in pregnancy among pregnant mothers compared with different studies in Ethiopia and different countries. Advanced maternal age, the respondent's level of education, and the number of live births were found to be independent determining factors for the level of knowledge on danger signs in pregnancy among pregnant mothers. Health facilities and healthcare providers should focus on antenatal care and the age and parity of the mother when giving information about danger signs in pregnancy. The Ministry of Health should provide reproductive health services in rural areas and encourage education for women. Further studies need to be conducted and include danger signs in the three trimesters using a qualitative study design.

Chronic Uterine Inversion due to Sub mucous Leiomyoma: Surgical Management with Reversed Technique of Vaginal Hysterectomy

Chronic uterine inversion is a very rare and life-threatening disease. It requires emergent treatment. Non puerperal uterine inversion is a rare clinical problem with diagnostic and surgical challenges. The patient may present with severe vaginal bleeding, discharge or pelvic pain. We are presenting a case report of a chronic non puerperal uterine inversion in a 30year old woman, she presented with vaginal bleeding, and a mass protruding from the vagina. Reversed technique of vaginal hysterectomy was done for her. Early diagnosis, immediate resuscitation and early treatment are important to prevent further complications.

Inflammatory Bowel Disease and Pregnancy

Inflammatory Bowel Disease and Pregnancy

Molar pregnancy with a coexisting living fetus: a case series

BackgroundCoexistence of molar pregnancy with living fetus represents a challenge in diagnosis and treatment. The objective of this study to present the outcome of molar pregnancy with a coexisting living fetus who were managed in our University Hospital in the last 5 years.MethodsWe performed a retrospective analysis of patients who presented with molar pregnancy with a coexisting living fetus to our Gestational Trophoblastic Clinic, Mansoura University, Egypt from September, 2015 to August, 2020. Clinical characteristics of the patients, maternal complications as well as fetal outcome were recorded. The patients and their living babies were also followed up at least 6 months after delivery.ResultsTwelve pregnancies were analyzed. The mean maternal age was 26.0 (SD 4.1) years and the median parity was 1.0 (range 0–3). Duration of the pregnancies ranged from 14 to 36 weeks. The median serum hCG was 165,210.0 U/L (range 7662–1,200,000). Three fetuses survived outside the uterus (25%), one of them died after 5 months because of congenital malformations. Histologic diagnosis was available for 10 of 12 cases and revealed complete mole associated with a normal placenta in 6 cases (60%) and partial mole in 4 cases (40%). Maternal complications occurred in 6 cases (50%) with the most common was severe vaginal bleeding in 4 cases (33.3%). There was no significant association between B-hCG levels and maternal complications (P = 0.3).ConclusionMaternal and fetal outcomes of molar pregnancy with a living fetus are poor. Counseling the patients for termination of pregnancy may be required.Trial registrationThe study was approved by Institutional Research Board (IRB), Faculty of Medicine, Mansoura University (number: R.21.10.1492).

Achievement of a 136-day delayed-interval delivery of a second twin with minimum intervention

The rate of multiple pregnancies in the past three decades has increased dramatically. Twin pregnancies have a higher risk of pregnancy loss owing to premature birth. Although the premature delivery of the first twin is usually followed by spontaneous birth of the second twin, there are ways to delay the delivery of the second twin to enhance survival and neonatal outcomes. However, there is insufficient evidence to support the role of any interventions such as cerclage, hospitalization, tocolytics, and/or antibiotics. As a result, the management of delayed interval for the delivery of the second twin varies depending on each case. The purpose of this study was to report the obstetric components of a successful delayed-interval delivery, with an emphasis on the current conflicts around the active management of the delayed interval delivery of the second twin. A case of a 40-year-old, G5P4, woman who had three cesarean sections is presented. She got pregnant with a dichorionic diamniotic twin. At 17 weeks of gestation, she developed sudden severe lower abdominal pain, vaginal bleeding, and spontaneous expulsion of the first fetus weighing 179 g. After delivery of the first twin, the vaginal bleeding became minimal, and the cervix was reconstituted soon, so cervical cerclage was not offered. The umbilical cord of the first fetus was cut at the level of the external cervical os, and the placenta was retained. She received intravenous fluids, anti-D prophylaxis, paracetamol, and antibiotics. The patient was keen to continue with the pregnancy and was informed about the risks and benefits. The management was mainly an outpatient basis after an initial short hospital stay of 6 days before being discharged (upon her request); during the follow-up, she did not develop any clinical manifestations of maternal infection. She was subjected to ANC at the outpatient clinic every 2 weeks, where vaginal culture, complete blood count, prothrombin time, and C-reactive protein levels and serial ultrasonography were checked consistently. The fetus showed adequate growth. After 136 days, she delivered by elective cesarean section a male baby weighing 2850 g at 37 weeks of gestation with good recovery. In certain situations, delayed delivery of the second twin of diamniotic dichorionic twin pregnancy may be a safe, simple with less interventions, and effective option to improve pregnancy outcome.

Knowledge regarding obstetric danger signs among pregnant women

Knowledge of obstetric danger signs is crucial to reduce maternal morbidity and mortality by identifying the problems earlier and avoiding the delay in seeking obstetric care. According to World Health Organization (WHO) more than 70% of maternal deaths occur due to obstetric complications and most of these deaths occur in developing countries. Most of these are preventable if pregnant women can identify these life-threatening danger signs on time and seek appropriate emergency obstetric care. This study was conducted to assess the knowledge of obstetric danger signs among pregnant women. A descriptive cross-sectional study was carried out from 15th July to 30th August 2021, 194 pregnant women who visited the Gynaecology Outpatient Department in Nepal Medical College Teaching Hospital, were enrolled for the study. Data were collected through face to face interviews using a structured questionnaire. The study findings revealed that overall knowledge on obstetric danger signs was suboptimal (3.1%). The median knowledge score of respondents on antenatal danger signs was 30.0% (Q1-Q3=17.5-40), intra-natal danger signs was 0.0% (Q1-Q3=0-20) and postnatal danger signs were 25% (Q1-Q3=0- 25). Severe vaginal bleeding was the most frequently mentioned danger sign in each of the three gestational periods (antenatal: 78.9%, intra-natal; 29.9% and postnatal; 39.7%). In conclusion, service providers and health management teams should emphasize on information, education and communication for every pregnant woman focusing on obstetric danger signs to have better awareness and thereby reduce adverse maternal and neonatal outcomes.

Twin pregnancy with complete hydatidiform mole: A case report

Objective: The association of twin pregnancy and a hydatidiform mole is a rare clinical condition. With the development of ultrasonography devices, prenatal diagnosis becomes easier.&#x0D; Case Report: A 21-year-old patient with gravida 1 parity 0 applied to our clinic with the complaint of vaginal bleeding at the 16th week of her pregnancy according to her last menstrual period. A pregnancy termination option was offered to the patient who was diagnosed with twin pregnancy consisting of a complete hydatidiform mole and co-existent fetus as a result of the examination and tests. Emergency laparotomy was planned for the patient who did not accept the pregnancy termination option because of severe vaginal bleeding at the 21st week of pregnancy.&#x0D; Conclusion: Although live births are reported in the literature in cases where twin pregnancy and hydatidiform mole are seen together, pregnancy termination due to vaginal bleeding may be required in earlier weeks.

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.

Accuracy of office hysteroscopy in the diagnosis of chronic endometritis

Background: To test the accuracy of office hysteroscopy in the diagnosis of chronic endometritis (CE) as compared to histopathological diagnosis. Methods: This prospective cohort study was conducted in a private hospital from July 2018 to January 2020. 220 infertile women were scheduled for first attempt of intracytoplasmic sperm injection (ICSI). Patients ranging in age from 20–40 with history of primary infertility scheduled for ICSI for the first time were included, while patients with chronic diseases, severe vaginal bleeding, previous failed ICSI, polycystic ovary syndrome (PCOS), or endometriosis were excluded. All patients received postmenstrual office hysteroscopy to rule out the presence of CE; at the same setting, endometrial biopsy was taken and sent for histopathological examination. Results: 174 cases (79.1%) were diagnosed as CE at hysteroscopy, while 162 (73.6%) cases were positive at histopathology. 99.4% of the cases presented with hyperaemia, followed by oedema in 74.7% and micro-polypi in 58.6% of cases with CE. There was a significant difference between the hysteroscopic and the histopathologic diagnosis of CE (p &lt; 0.001). The sensitivity, specificity, and positive and negative predictive values of hysteroscopy were 93.83%, 62.07%, 87.36% and 78.26% respectively. Conclusions: Office hysteroscopic evaluation is relatively accurate on its own but can be further confirmed by CD138 staining.

Spontaneous angular dichorionic diamniotic twin pregnancy: a case report

To report a peculiar case of ultrasound diagnosis of spontaneous angular twin pregnancy. In literature, the terms "angular," "interstitial," and "cornual" pregnancies are often used inappropriately. Confusion in terminology may have contributed to difficulties in developing diagnostic ultrasound criteria to differentiate these ectopic pregnancies. Case report. Obstetrics and Gynecology, Community Hospital "S. Maria delle Croci." A 28-year-old patient with a previous cesarean delivery was admitted to our hospital for management of a presumed angular ectopic pregnancy. Transvaginal ultrasound confirmed an ectopic dichorionic diamniotic twin pregnancy eccentrically located in the right superior angle of the uterine cavity: the first gestational sac appeared to have right angular implantation, whereas the second gestational sac seemed to deepen inside the myometrium, with a thin myometrial margin of only 3 mm. After discussing the risks, the patient requested to proceed with termination. A single intramuscular injection of 75 mg of methotrexate was administered, followed by ultrasound-guided hysterosuction after 19 days due to severe vaginal bleeding. An early and accurate ultrasound diagnosis of a high-risk condition allowed for conservative medical treatment. The serum beta-human chorionic gonadotropin levels progressively decreased. After 1 month, a clinical and ultrasound examination showed a regular endometrial line with a regular reappearance of menstrual bleeding. Although there are remarkable advances in ultrasound techniques, angular pregnancy remains a condition of difficult diagnosis and management; it is potentially dangerous and may lead to severe complications. An early and accurate diagnosis of this condition is necessary to avoid complications and individualize the subsequent management.