Ruptured extrauterine pregnancy

Extrauterine pregnancies contribute substantially to maternal mortality in all parts of the world. The most common cause of these deaths is massive bleeding after rupture of the ectopic pregnancy. The advent of transvaginal ultrasonography in early pregnancy and the use of quantitative measurement of the β-unit of human chorionic gonadotropin have revolutionized the management of this condition. These diagnostic modalities allow its early detection and, in many cases, treatment before rupture occurs. There is an ever increasing body of evidence supporting expectant, medical, and surgical management of ectopic pregnancy according to certain criteria. The indications and criteria for the different management options are described in the literature and in clear guidelines from institutions such as the Royal College of Obstetricians and Gynaecologists. Methotrexate, in a single dose protocol, is widely used in the medical management of ectopic pregnancy. Surgical therapy can be either laparoscopic or via laparotomy. Be that as it may, ruptured ectopic pregnancy will continue to present as a gynecologic emergency requiring prompt and appropriate care. Resuscitation of these patients should be an organized, systematic, and rapid process with the ultimate goal of getting them to the operating theatre in the best possible hemodynamic status. The aim of surgery should be to stop active bleeding by the most expedient method. The use of autotransfusion is well established in cardiac surgery, vascular surgery, orthopedic surgery, and trauma. Using autologous blood should be considered also in the treatment of ruptured extrauterine pregnancy when faced with massive bleeding and a need for transfusion. Advanced abdominal pregnancy is a rare condition with high perinatal and maternal morbidity and mortality. Placental management at delivery remains a dilemma. The risk of massive bleeding upon removal must be balanced against the risk of infection and other complications during the long time needed for resorption of the placenta if left in situ. Despite a reduction in maternal mortality due to ectopic pregnancy in the developed world during the preceding period, it would appear that no further inroads have been made in the last two decades. In developing countries, the problem is far greater, and problems with resources and infrastructure persist. It remains a challenge to all practitioners caring for women to apply available resources and use the published evidence-based guidelines to manage these women effectively and safely. © European Board and College of Obstetrics and Gynaecology 2006.Revie

Oral contraception: Five important issues

The dosage of the hormones used in the combined oral contraceptive pill have, over the past 40 years, continually decreased in order to provide formulations with minimum side effects while still retaining efficacy. Women are concerned that long-term use of combined oral contraceptives (COCs) increases health risks (including an increased risk of cancer or cardiovascular disease). In this article we would like to highlight some of the above issues and some of the commonly asked questions. This would enable us to provide the necessary advice and guidance to our patients. Oral contraception is an area in the health sector where new products are constantly developed and this means that, to give patients the best available advice, general practitioners, pharmacists and gynaecologists need to stay abreast with the latest literature and developments.Revie

Endotoxic shock after gamete intrafallopian transfer

Objective: To report an extremely rare case of endotoxic shock due to Enterobacter cloacae that occurred after laparoscopy for gamete intrafallopian transfer (GIFT) in a nulligravid woman. Design: Private fertility center in Cape Town, South Africa. Setting: Case report. Patient(s): A 34-year-old woman with primary infertility. Intervention(s): Routine preparation for GIFT procedure, sonar aspiration to obtain oocytes, followed by GIFT. Endotoxic shock developed within hours after the procedure, followed by admission to the intensive care unit, intravenous antibiotic therapy, mechanical ventilation, and abdominal hysterectomy. Main Outcome Measure(s): Preventing patient mortality and morbidity. Result(s): Discharge from the intensive care unit occurred on day 11 after GIFT, which was day 8 after surgery. A MEDLINE search (1980 to 2003) found no previous literature on endotoxic shock associated with assisted reproduction. Conclusion(s): Gram-negative infection with subsequent endotoxic shock after assisted reproductive techniques is extremely rare. As this case report shows, early diagnosis and active management of these cases are mandatory to prevent serious complications and mortality. ©2005 by American Society for Reproductive Medicine.Articl