BackgroundHysteroscopic adhesiolysis anatomically restores the uterine cavity in cases of Asherman’s syndrome (AS); however, the extent of endometrial fibrosis could determine the pregnancy outcome.ObjectivesTo determine whether endometrial thickness could influence pregnancy outcome of hysteroscopic adhesiolysis in women with a history of AS.Subjects and methodsThis was a retrospective cohort study that included 41 women who attended Women’s Specialized Hospital, King Fahad Medical City from December 2008 to December 2015, presented with a history of infertility or recurrent pregnancy loss, and were diagnosed with intrauterine adhesions and treated by hysteroscopic adhesiolysis. To analyze the causative factors of AS, history of curettage, miscarriage, postpartum hemorrhage, hysteroscopy, endometritis, and any uterine surgery were recorded. Patients were followed up for 2 years to account for pregnancy. Patients were divided into two groups based on measurement of endometrial thickness in the midsagittal plane at mid-cycle of a menstrual period. Group A consisted of 26 patients with endometrial thickness ≤5 mm, and group B included 15 patients with endometrial thickness >5 mm. The main outcome measures included endometrial thickness and pregnancy outcome.ResultsGroup A had significantly (P<0.001) lower pregnancy rates compared with group B (38.4% versus 80%, respectively). Five of 10 pregnancies (50%) from group A miscarried, compared with 1 of 12 (8.3%) pregnancies in group B. This was statistically significant (P<0.001).ConclusionPregnancy rates were observed to be higher when the endometrium was >5 mm in thickness among patients with AS and miscarriage rates may be reduced in this group.

BackgroundOf all patients undergoing emergency surgery for acute pelvic pain, approximately 2.7% of cases are caused by ovarian torsion. We report a rare occurrence of bilateral ovarian torsion in a young woman.Case presentationWe report the case of a 20-year-old white woman who presented with sudden onset of severe lower abdominal pain and nausea. Similar episodes of pain were experienced in the previous few months and diagnosed as a case of bilateral ovarian cyst. She was found to have a bilateral ovarian torsion caused by adnexal mass. She was treated by laparoscopic detorsion, left salpingo-oophorectomy, and right cystectomy.ConclusionThis case highlights the need to perform an early laparoscopic surgical intervention in cases of bilateral ovarian mass because of the greater chance for their torsion and subsequent effects on fertility.

Women with Asherman syndrome (AS) have intrauterine adhesions obliterating the uterine cavity. Hysteroscopic March classification describes the adhesions which graded in terms of severity. This study has been designed to assess the prevalence and association between of clinical presentations, potential causes, and hysteroscopic March classification of AS among infertile women with endometrial thickness.A retrospective descriptive study was carried out that included 41 women diagnosed with AS. All of the patients underwent evaluation and detailed history. All cases classified according to March classification of AS were recorded. Patients were divided into 2 groups based on measurement of endometrial thickness. Group A consisted of 26 patients with endometrial thickness ≤5 mm, and group B included 15 patients with endometrial thickness >5 mm.The prevalence of AS was 4.6%. Hypomenorrhea was identified in about 46.3%, and secondary infertility 70.7%. History of induced abortion, curettage, and postpartum hemorrhage were reported among 56.1%, 51.2%, and 31.7%, respectively. AS cases were classified as minimal in 34.1%, moderate 41.5%, and severe among 24.4% as per March classification. Amenorrhea was reported by 23.1% of women in group A, compared to 0% in group B (P = .002). Ten of 26 patients (38.5%) from group A had a severe form of March classification, compared with 0 of 15 patients (0%) in group B. This was statistically significant (P < .001).The thin endometrium associated with amenorrhea and severe form of March classification among patients with AS.

The giant ovarian serous cystadenoma is a rare finding and often benign. The use of the laparoscopic approach versus open approach for the management of huge ovarian cysts is controversial. We report a case of a 27-year-old woman with a history of increasing abdominal girth over a period of two years along with radiological investigations revealed a large tumor arising from the right ovary treated by complete laparoscopic extirpation of a giant ovarian cyst. The complete laparoscopic approach for huge cyst is a feasible treatment when having a normal tumor marker profile and benign imaging appearance. In addition to the advantages of laparoscopic surgery, it is less invasive, with perfect cosmetic outcome and shorter hospital stay, which are particularly important for young women.

Women with Asherman syndrome (AS) have damaged endometrium and reduced blood flow to the uterus and placenta which may lead to low birth weight and several obstetric complications.The objective is to determine the association between low birth weight and obstetrical complications in women with AS compared to women with normal intrauterine cavity.A retrospective case-control study was conducted in Women's Specialized Hospital, King Fahad Medical City, from December 2008 to December 2015. Pregnant women with AS undergoing hysteroscopic adhesiolysis who presented to our clinic were matched for age, parity, body mass index, methods of conception, and gestational age to pregnant women without AS based on a 1:3 ratio. The main outcome measure included birth weight and obstetrical complications.The study included 56 women with 14 cases and 42 controls. Pregnant women with AS had significantly lower birth weight (2.23 ± 0.28 kg) compared with pregnant women without AS (3.13 ± 0.383 kg) (P < .001 odds ratio [OR] 0.029, 95% confidence interval [CI] 0.006–0.148, P = .001). Complications of delivery including retained placenta, placenta previa, and fetal death were significantly higher in patients with AS compared with controls 28.6% 7.1%, and 7.1% compared to 4.8%, 0%, and 0%, respectively. This was statistically significant (P < .001).Pregnant women with AS delivered low birth weight newborns and had more obstetrical complications as compared with pregnant women with normal cavity.

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Rationale:Cesarean scar twin pregnancy is exceedingly rare and it remains to be a life-threatening condition even in the early weeks of gestation. Because of its rare occurrence, there is no consensus on the treatment modality of cesarean ectopic pregnancy.Patient concerns:A 41-year-old, woman, gravida 7, para 6, with a history of low transverse cesarean section 2 years back presented with an estimated 6 weeks gestational age and viable spontaneous twin, monochorionic diamniotic gestation. The patient presented to the Emergency Department with complaints of vaginal bleeding and mild lower abdominal pain for 5 days.Diagnoses:An ultrasound examination was performed demonstrating a single intrauterine gestational sac with 2 viable embryos (monochorionic diamniotic) implanted in the lower uterine segment at the level of the prior cesarean section scar. A diagnosis of viable cesarean scar twin pregnancy was made.Interventions:A 2 doses of 50 mg/m2 methotrexate (MTX) was given intramuscularly. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (β-hCG) and ultrasound.Outcomes:Patient was followed up with β-hCG weekly levels which became 0 after 68 days of treatment. During the follow-up, the patient was asymptomatic, no side effects of MTX were noticed.Lessons:We reported a rare case of viable monochorionic diamniotic twin pregnancy on a cesarean scar that was successfully treated with systemic MTX without any additional therapy. Additionally, the decline of β-hCG in twin ectopic cesarean scar pregnancy appears to be similar to a singleton ectopic pregnancy.

Rationale:Ectopic mammary gland tissues occur in about 2% to 6% of women in general population. Vulva is considered a rare site for the ectopic breast tissue.Patient concerns:We report a rare case of a 27 year-old woman, para 2 and presenting as a vulvar mass in the postpartum period.Diagnoses:Ectopic mammary tissue in vulva.Interventions:The mass was removed by wide local excision. Histopathological assessment revealed features of ectopic mammary tissueConclusion:The vulvar region is one of the reported sites for ectopic breast tissue in the body. The presence of a rapidly enlarging, well-encapsulated mass in the vulvar region associated with recent delivery or lactation is suggestive of ectopic breast tissue.Lessons:It is important for clinicians to get a good history and consider ectopic breast tissue on vulva in postpartum women and confirm diagnosis via biopsy with histopathological examination.