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we deliver a viable fetus with dislocated fracture of long bones? Should delivery always be by Cesarean section to minimize further movements of the
bone fragments? What about fractures that look partly healed, especially in
signicant misalignment? We do not have prospective studies and long-term
follow-ups. We should mostly rely on the biology and recommendations from
neonates and infants. However, is this enough for excellent outcomes? Maybe
this new edition would not give all the answers, but it could open our eyes and
minds to think more profoundly about these sporadic cases in our clinical
practice.
I express my gratitude to Donatella Rizza and the staff at Springer, who
have supported the project from the beginning and helped bring this book to
fruition. Therefore, I hope that Cicero was not right about my book. I hope
that the reader will enjoy reading it!
Zagreb, Croatia GoranAugustin
Preface to the Third Edition
Preface to the Second Edition
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He who combines the knowledge of physiology and surgery, in addition to the artistic side of his subject, reaches the highest ideal in medicine. (Christian Albert
Theodor Billroth)
I am fortunate again to have the opportunity of changing my mind, of clarifying
confusion and my confused thinking, of correcting misstatements, as well as
attempting to remain contemporary. I am doomed to the embarrassment of living
with my previous inaccuracies. Still, it is better to recant than to be accused of having a pertinacious little mind. (Marvin Corman (Preface to the sixth edition of
Colon and Rectal Surgery))
If a man will begin with certainties, he shall end in doubts; but if he will be content
to begin with doubts, he shall end in certainties. (Sir Francis Bacon)
When I started writing the rst edition of this book, I read the foreword of
one book, from an author whom I do not remember, where he wrote that he
did not know that it was more difcult and more time-consuming to write the
second edition of the same book. At rst, I was surprised because I thought
one could change several gures, add a little new text, and complete the new
edition. I recalled the author’s words and statements when I started improving
the rst edition. It is the whole truth! I was surprised when, several months
after the rst edition was published, I started to read my book again. I was
surprised how many misinterpretations, errors, or scientic and clinical
“gaps” were present. I was ashamed of how incomplete and inconsistent the
book I wrote was. At the same time, I started to read the new sixth edition of
Marvin Corman’s book—Colon and Rectal Surgery. Before going to the spe-
cic topics that interested me, I read the Preface. And I was thrilled, relaxed,
satised, and fullled at the same time. The citation that I took from Corman’s
Preface is true. Then, it was easier to nish this second edition, knowing it
would be better than the rst edition (and probably worse than future editions). Every chapter is expanded and updated, and four new chapters are
added. The chapter on urologic emergencies helps to differentiate conditions
that usually do not require operative interventions. Perioperative and anesthetic considerations, part of every chapter in the rst edition, are concentrated in a separate chapter and signicantly expanded. Many of these
considerations are the same for the most acute abdominal conditions during
pregnancy. One of the added chapters is especially interesting. It is about
increased intra-abdominal pressure during pregnancy. This issue is complex,
even in the general population. In pregnancy, it has additional difculty
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Preface to the Second Edition
during the diagnostic workup and selecting appropriate treatment strategies
for both the mother and the fetus.
My father, also an abdominal surgeon, watched me while writing the second edition for 2years, day by day. Once, he came to me, knowing that I am
the sole editor and author, and said: “This book is concentrated energy, so
much energy that could ll an atomic bomb.” I can conrm that his statement
is true when the text is completed. Concentrated energy or concentrated
knowledge is what I want to share with every reader!
And now I repeat my plea from the Preface of the rst edition. Contact me
for any errors, misinterpretations, or medical/surgical mistakes in the text
because I would like to improve (further editions of) this interesting subject.
Dear authors, publish cases of the acute abdomen during pregnancy and publish comprehensive reviews so that the medical community could have a better insight into the incidence, etiology, diagnosis, treatment, and maternal and
fetal outcome for all causes of the acute abdomen during pregnancy. Dear
reviewers and editors of medical journals, please be sensitive to these important topics. Who knows, maybe, oneday, a journal, for example, Journal of
Abdominal Surgery in Pregnancy or Digestive Diseases in Pregnancy, will be
created.
Zagreb, Croatia GoranAugustin
Preface to the First Edition
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The art and science of asking questions is the source of all knowledge. (Thomas
Berger)
What has given me the most joy in my life is the establishment of a school that carries on my aspirations and aims, be it scientic or humanitarian thereby ensuring a
legacy for the future. (Theodor Billroth, 1893)
Earlier diagnosis means better prognosis. (Zachary Cope, 1921)
How did the idea for the book come? Here is the answer. Acute abdomen is
still one of the most exciting conditions in (emergency) surgery and medicine. The clinician needs to make the diagnosis and the indication for the
operation as fast as possible. Then the operator should operate with the lowest
possible morbidity and mortality. This has been known for over a century.
Another difculty arises when that clinician has a pregnant patient with an
acute abdomen. Now they are dealing with two human beings at the same
time. Also, the pregnant patient has slightly changed intraperitoneal anatomy
and physiology, making the diagnosis more difcult.
During the last 7years, I started to study more on the causes of acute abdomen during pregnancy. Searching through the literature, I found very few
reviews on the subject. Unfortunately, that was expected because acute abdomen during pregnancy is a rare group of conditions. After excluding the most
common causes, such as acute appendicitis and acute cholecystitis, the clinician will deal with other pathologies during pregnancy once in several years,
sometimes once in a career. When I comprehended that, I started to study,
write, and publish articles about different topics of the acute abdomen during
pregnancy. When I tried to nd some texts covering the whole topic, I could
not nd these. Then it came to me that I needed to write a book about Acute
Abdomen During Pregnancy, rst to help myself and then to help other clinicians dealing with this rare subject. Interestingly, some names in medicine,
gynecology, and surgery that are not so famous or known were the rst to
treat such cases in medical history. It was interesting for me to read about
them and to put them in the book. Mostly, these persons were more famous
for other achievements in their medical elds.
There are two problems in writing a book that should have guidelines and
recommendations on the topics included. First, it is the (extreme) rarity of
these conditions. Second, the acute onset is unpredictable in the severity and
the time of presentation. These facts preclude the possibility of randomized
studies needed for validated guidelines and recommendations in medicine.
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Therefore, some of the recommendations in the book are not adequately validated. Still, due to the rarity (some diseases have less than 50–100 cases
published in 100years), I tried to combine the recommendations from the
acute abdomen in the general population and from the opinions of the authors
(and myself) of published case reports. Therefore, many facts from these case
reports are copied into this textbook. Also, the comprehensiveness of the
chapters is not equal and mostly depends on the frequency of specic conditions during pregnancy. Hence, the most extensive chapters include acute
appendicitis, acute cholecystitis, intestinal obstruction, and abdominal
trauma, the most common conditions. I tried to include as many case reports
as possible so the reader could have their own opinion about the topic and
develop ideas for further research. After completing the manuscript, I read it
thoroughly and realized that many things could be written better. Margaret
Atwood’s tip for writers motivated me to go further: “If I waited for perfec-
tion, I would never write a word.” Therefore, I would never write this book if
I had waited for perfection.
Additionally, it should be mentioned that possibly any cause of acute
abdomen can occur during pregnancy, and a detailed description would lead
to an enormous number of unnecessary pages. Therefore, a short description
of the disease is presented in conditions with only one or several cases published. It is difcult to say if this book is more suitable for gynecologists or
general/abdominal surgeons. Some parts will be more interesting to the surgeon, while others to the gynecologist, especially therapeutic considerations.
The diagnostic workup will be interesting to every reader. Some photos (gures) in the text are not of excellent quality. Still, because of the extreme
rarity of some conditions, it is impossible to obtain other photographs of
similar or identical pathology.
And my nal plea… to every reader… please contact me about any type
of errors, misinterpretations, and medical/surgical mistakes in the text
because it would improve (further editions of) this interesting subject. Contact
me if you have any questions about the subject. Also, any reader dealing with
this subject could feel free to contact me to be an author of one of the chapters
in (possible) further editions of this book. My other plea to the reader is to
publish cases of the acute abdomen during pregnancy so the medical community could have a better insight into the incidence, etiology, diagnosis,
treatment, and maternal and fetal outcome for all causes of the acute abdomen during pregnancy.
I hope the reader will enjoy reading the book as much as I enjoyed creating it!
Preface to the First Edition
Zagreb, Croatia GoranAugustin
Contents
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Part I General Considerations
1 Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.1 Examinations That Do Not Require Verication of
Pregnancy Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.1.2 Examinations That May Require Verication of
Pregnancy Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2 Abdominal Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3 Abdominal CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.4 Abdominal MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.5 MRCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.6 Nuclear Medicine Examinations . . . . . . . . . . . . . . . . . . . . . . 11
1.7 Radiologic Interventional Techniques . . . . . . . . . . . . . . . . . . 11
1.8 ERCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.8.1 Radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.8.2 Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.8.3 Contrast Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.8.4 Maternal and Fetal Outcomes . . . . . . . . . . . . . . . . . . 13
1.9 Endovascular Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.10 Intraoperative Cholangiography. . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2 Anesthetic and Perioperative Management . . . . . . . . . . . . . . . . 17
2.1 Anesthetic Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.1.1 Anesthetic Medications . . . . . . . . . . . . . . . . . . . . . . . 18
2.1.2 Airway Management . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.1.3 Intraoperative CO2 Monitoring . . . . . . . . . . . . . . . . . 25
2.1.4 Extracorporeal Membranous Oxygenation . . . . . . . . 25
2.2 Perioperative Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.2.1 Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.2.2 Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.2.3 Thromboprophylaxis and Anticoagulation . . . . . . . . 27
2.3 Perioperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.3.1 Fetal Heart Rate Monitoring . . . . . . . . . . . . . . . . . . . 33
2.3.2 Perioperative Nutrition . . . . . . . . . . . . . . . . . . . . . . . . 34
2.3.3 Hemorrhage Management . . . . . . . . . . . . . . . . . . . . . 37
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
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3 Increased Intra-abdominal Pressure . . . . . . . . . . . . . . . . . . . . . . 45
3.1 Physiology and Pathophysiology . . . . . . . . . . . . . . . . . . . . . . 45
3.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.1.2 The Physiology of Normal Pregnancy . . . . . . . . . . . . 46
3.1.3 Intra-abdominal Pressure in Normal Pregnancy . . . . 46
3.1.4 Pathophysiology of IAH/ACS . . . . . . . . . . . . . . . . . . 48
3.2 Etiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.2.1 Nonoperative Conditions . . . . . . . . . . . . . . . . . . . . . . 51
3.2.2 Operative Conditions . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.4.1 Intra-abdominal Pressure Measurement . . . . . . . . . . 60
3.4.2 Laboratory Findings . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.4.3 Plain Chest X-Ray . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.4.4 Abdominal Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . 61
3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.5.1 Nonoperative Treatment . . . . . . . . . . . . . . . . . . . . . . . 61
3.5.2 Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.5.3 Obstetric Management . . . . . . . . . . . . . . . . . . . . . . . . 64
3.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.6.1 Maternal Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.6.2 Fetal Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Contents
4 Acute Abdomen-Induced Preterm Labor . . . . . . . . . . . . . . . . . . 75
4.1 Denitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
4.2 Physiology of Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.2.1 Myometrial Contractility . . . . . . . . . . . . . . . . . . . . . . 76
4.2.2 Cervical Remodeling . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.2.3 Decidual/Membrane Activation . . . . . . . . . . . . . . . . . 77
4.2.4 Prostaglandins and Parturition . . . . . . . . . . . . . . . . . . 77
4.3 Etiopathogenesis of Preterm Labor . . . . . . . . . . . . . . . . . . . . 78
4.3.1 Inammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
4.3.2 Maternal and Fetal Stress . . . . . . . . . . . . . . . . . . . . . . 84
4.3.3 Decidual Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . 86
4.3.4 Maternal Nutritional Status . . . . . . . . . . . . . . . . . . . . 88
4.3.5 Final Common Pathway . . . . . . . . . . . . . . . . . . . . . . . 89
4.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
4.5.1 Prediction of Preterm Labor. . . . . . . . . . . . . . . . . . . . 90
4.5.2 Preterm Premature Rupture of Membranes . . . . . . . . 90
4.5.3 Placental Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.6.1 Nontocolytic Treatment . . . . . . . . . . . . . . . . . . . . . . . 92
4.6.2 Tocolytic Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.6.3 Combination Treatment . . . . . . . . . . . . . . . . . . . . . . . 99
4.6.4 Placental Abruption Treatment . . . . . . . . . . . . . . . . . 100
4.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Contents
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4.7.1 Fetal Inammatory Response Syndrome . . . . . . . . . . 101
4.7.2 Fetal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.7.3 Fetal Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.7.4 Maternal Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5 Fetal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
5.1 Fetal Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
5.2 Blunt Fetal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
5.2.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
5.2.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
5.2.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 121
5.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
5.2.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 125
5.2.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
5.2.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
5.3 Penetrating Fetal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
5.3.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
5.3.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
5.3.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 135
5.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
5.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
5.3.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Part II Gynecology
6 Adnexal Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
6.2 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.3 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.4 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.4.1 Adnexal Mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.4.2 Anatomic Variations of Adnexa . . . . . . . . . . . . . . . . . 155
6.4.3 Assisted Reproductive Technologies . . . . . . . . . . . . . 155
6.4.4 Pregnancy and Trimester . . . . . . . . . . . . . . . . . . . . . . 156
6.5 Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
6.6 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
6.6.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
6.6.2 Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . 157
6.7 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.8 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.8.1 Laboratory Findings . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.8.2 Transvaginal Ultrasound . . . . . . . . . . . . . . . . . . . . . . 158
6.8.3 Abdominal CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
6.8.4 Abdominal MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
6.9 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
6.9.1 Operative Principles . . . . . . . . . . . . . . . . . . . . . . . . . . 161
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6.9.2 Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . 164
6.9.3 Obstetric Management . . . . . . . . . . . . . . . . . . . . . . . . 167
6.10 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
6.10.1 Maternal Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
6.10.2 Fetal Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
7 Isolated Fallopian Tube Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . 173
7.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
7.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
7.3 Etiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
7.3.1 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
7.3.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
7.4 Classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
7.5 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
7.6 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
7.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
7.7.1 Laboratory Findings . . . . . . . . . . . . . . . . . . . . . . . . . . 176
7.7.2 Abdominal Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . 176
7.7.3 Abdominal CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
7.7.4 Abdominal MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
7.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
7.8.1 Abdominal Entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
7.8.2 Operative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 179
7.8.3 Obstetric Management . . . . . . . . . . . . . . . . . . . . . . . . 181
7.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
7.9.1 Maternal Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
7.9.2 Fetal Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Contents
8 Complex Ovarian Mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
8.1 Incidence and Classication . . . . . . . . . . . . . . . . . . . . . . . . . 185
8.1.1 Ovarian Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
8.1.2 Ovarian Teratoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
8.1.3 Ovarian Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . 187
8.1.4 Ovarian Endometrioma . . . . . . . . . . . . . . . . . . . . . . . 188
8.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
8.3 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
8.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
8.4.1 Laboratory Findings . . . . . . . . . . . . . . . . . . . . . . . . . . 189
8.4.2 Abdominal Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . 190
8.4.3 Abdominal MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
8.5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
8.5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
8.5.2 Conservative Treatment . . . . . . . . . . . . . . . . . . . . . . . 192
8.5.3 Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
8.5.4 Anesthetic and Perioperative Management . . . . . . . . 198
8.5.5 Adjuvant Chemotherapy . . . . . . . . . . . . . . . . . . . . . . 198
8.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
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8.6.1 Maternal Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
8.6.2 Fetal Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
9 Ruptured Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
9.1 Ectopic Pregnancy in General . . . . . . . . . . . . . . . . . . . . . . . . 203
9.1.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
9.1.2 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
9.1.3 Classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
9.1.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 205
9.1.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 208
9.1.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
9.1.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
9.1.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
9.2 Ruptured Cornual Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 214
9.2.1 Denition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
9.2.2 Incidence and Pathophysiology . . . . . . . . . . . . . . . . . 215
9.2.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 215
9.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
9.2.5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
9.2.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
9.3 Abdominal Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
9.3.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . 222
9.3.2 Classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
9.3.3 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
9.3.4 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
9.3.5 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 223
9.3.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
9.3.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
9.3.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
9.4 Primary Hepatic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . 230
9.4.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . 230
9.4.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
9.4.3 Risk Factors and Pathophysiology . . . . . . . . . . . . . . . 230
9.4.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 230
9.4.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 230
9.4.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
9.4.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
9.5 Primary Ovarian Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . 237
9.5.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . 237
9.5.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
9.5.3 Risk Factors and Pathophysiology . . . . . . . . . . . . . . . 238
9.5.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 239
9.5.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
9.5.6 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 239
9.5.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
9.5.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
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