First trimester diagnosis of partial mole

Background Partial mole is one of the two distinctive subtypes of hydatidiform mole. It is usually paternally derived triploid conceptions in which embryonal development occurs in association with trophoblastic hyperplasia. The definite diagnosis is confirmed by pathological and cytogenetic studies. Ultrasound might be helpful to diagnose partial mole in the first trimester.Case A 25-year-old woman, gravida 2, para 0-0-1-0, was initially seen for antenatal care at 6 weeks pregnant. Ultrasound was undertaken at 13 weeks pregnancy due to her first fetal anomaly, which demonstrated partial mole and embryonic death. The serum hCG was 190,900 mIU/ml. Suction curettage was performed without complication. Histopathological study confirmed partial mole and cytogenetic study of the placenta revealed an uncommon karyotype, mosaicism of triploid (69,XXX/69,XXY). Serum hCG was declined and negative at 8 weeks. The patient was well and serum hCG remained normal throughout 6 months of follow-up.Conclusion Although the majority of partial mole pregnancies cannot be detected by routine first trimester ultrasound examination, first trimester ultrasound can be helpful in some cases, such as this one. If partial mole is sonographically suspected, it should be confirmed with histopathology and cytogenetic studies. The management is similar to complete mole including prompt evacuation and careful monitoring of hCG.     

Prenatal diagnosis of a fetal intracranial tumor

Introduction The commonest fetal intracranial tumor is the teratoma. The prognosis is poor with death usually occurring shortly after birth. Modern high resolution ultrasound scanners facilitate examination of the cranial contents, allowing earlier diagnosis.Case report A fetus with a congenital intracranial teratoma presenting with a disproportionately enlarged head at 36 weeks gestation is presented. The infant died of respiratory failure within 24 h of birth. On postmortem examination the histologic report revealed an immature teratoma. Summary This article describes the prenatal sonographic diagnosis of a rare case of intracranial immature teratoma in a fetus at 36 weeks gestation.     

Doppler ultrasound of the uterine artery in the prediction of severe complications during low-risk pregnancies

Aim The aim of this prospective study was to assess the role of uterine artery colour Doppler waveform analysis in the prediction of adverse pregnancy outcome such as preeclampsia, intrauterine growth retardation, placental abruption or a combination of outcome parameters.Methods Various uterine artery Doppler ultrasound parameters (RI>0.58, RI>0.7 and unilateral or bilateral notching) were tested. A second objective was to compare the predictive power of uterine artery Doppler ultrasound at 19–22 gestational weeks and 23–26 weeks gestation for an adverse pregnancy outcome.Results The mean time of delivery was 39+0 weeks of gestation. Eight newborns (2%) were delivered before 34 weeks of gestation. The mean birth weight was 3,240 g. Dystrophic fetuses (<10% percentile) were registered in 35 cases (10%). In 31 of the 346 women (9%) a cesarean section was performed because of abnormal fetal heart recording. Preeclampsia was diagnosed in 17 cases (5%). In 5 cases (1.4%) a placental abruption and 2 (0.6%) intrauterine fetal deaths were diagnosed. The sensitivity of notching for the prediction of preeclampsia was 88% and for the prediction of a severe pregnancy complication (preeclampsia and/or intrauterine growth retardation and/or intrauterine fetal death and/or placental abruption) at any gestational age was 62% with relative risks of 9.7 and 2.2, respectively. The sensitivity of notching for severe pregnancy complications requiring delivery before 34 weeks was 64% with a relative risk of 2.4. The sensitivity of notching in the uterine arteries for developing an IUGR was 56% with a relative risk of 1.7.Conclusion The predictive value of uterine artery Doppler for adverse pregnancy outcome in a low-risk population is of limited diagnostic value. Performing uterine artery Doppler studies at 23–26 weeks gestation instead of 19–22 weeks gestation increases the predictive value for adverse pregnancy outcomes.     

Use of icodextrin 4% solution in the reduction of adhesion formation after gynaecological surgery

Our objective was to use Adept Registry for clinical evaluation (ARIEL) to monitor ease of use, acceptability and safety of icodextrin 4% solution during routine gynaecological surgery. Surgeons from six European countries were asked to complete anonymised data collection forms for patients undergoing gynaecological laparoscopy or laparotomy procedures with an associated risk of adhesion formation. Gynaecological surgeons from 150 centres recorded patient demographics, use of icodextrin 4% solution and adverse events, and made subjective assessments of ease of use and patient acceptability with the agent. The gynaecological surgery registry included 2,882 patients; 72% (n=2,069) underwent laparoscopies. Most surgeons rated the ease of use (viewing of surgical field and handling of tissues) of icodextrin 4% solution as excellent or good and leakage from the surgical site as normal (approximately 60% of laparoscopies and laparotomies) or less than normal (30% and 23%, respectively). Abdominal discomfort was rated by surgeons as as expected in 68% of laparoscopy patients and 67% of laparotomy patients and less than expected in 24% and 26%. Abdominal distension values were comparable. The incidence of adverse events (laparoscopy 7.5%; laparotomy 13.9%) reflected expected rates in gynaecological surgery. ARIEL data indicate that icodextrin 4% solution was well tolerated and easy to use for the reduction of adhesion formation following gynaecological surgery.     

Association between method of delivery,puerperal complication rate and postpartum hysterectomy

Objectives The aim of this study was to assess current maternal obstetrical risk associated with different modes of delivery concerning puerperal complications, especially postpartum hysterectomy.Materials and methods We studied the perinatal survey data 1998–2001 of the German state of Baden-Württemberg, comparing complication rates associated with method of delivery of different groups of pregnant women. For statistical analysis ²-test, Fishers exact test, Mantel-Haenzel statistics and relative risks (RR) were used to describe the risk to those exposed to the likelihood of undergoing a caesarean section.Results Surgical delivery is associated with a significantly higher total puerperal complication rate and risk of postpartum hysterectomy (p<0.0001, sample size = 354,160). If primary caesarean section for a singleton in cephalic presentation and more than 37 weeks gestation is tested separately versus spontaneous vaginal delivery of a singleton in cephalic presentation and more than 37 weeks gestation, the RR for puerperal complications is 3.38 (95% confidence interval [CI] 2.94–3.77), and the RR for postpartum hysterectomy is 7.96 (95% CI 3.96–16.00).Conclusions Surgical method of delivery is also subject to a propensity towards puerperal complications when primary caesarean sections are considered separately. The results support the concept that reducing caesarean delivery likelihood is a correct approach to providing primary prevention of caesarean-related maternal morbidity.Study based on the Perinatal Survey of Baden-Württemberg/Germany     

Conservative treatment of ectopic pregnancy with methotrexate in a nonoperable patient with Crohn’s disease

We present a case of conservative management using methotrexate for ectopic pregnancy in a nonoperable patient with complicated severe Crohns disease. This case demonstrates the successful use of methotrexate in an unusual situation in which laparoscopy or laparotomy could have further jeopardised the patients medical status.     

Complete hydatidiform mole with coexistent live fetus in dichorionic twin gestation

Case report A 28-year-old patient gravida 3, para 2 was admitted at 16 weeks gestation with the diagnosis of complete hydatidiform mole with coexistent live fetus (CHMCF) in dichorionic twin gestation. The HCG level was 530,000 mIU/ml. The pregnancy was terminated by hysterotomy. Outcome Histopathologic analysis revealed a hydatidiform mole and a 17-week-old male fetus attached to the normal looking placenta by a double-vesseled cord. A final karyotype on cord blood samples confirmed normal 46 XY. Weekly performed serial HCG values showed declining trend and were undetectable by 10 weeks post delivery.     

Pregnancy outcome after loop electrosurgical excision procedure for the management of cervical intraepithelial neoplasia

Objective: Previous studies have shown conflicting results on the outcome of pregnancy following loop electrosurgical excision procedure (LEEP). The purpose of this study was to evaluate whether LEEP affects the outcome of pregnancy after 20 weeks gestation. Methods: This is a matched cohort study of all women who had a LEEP for a biopsy-confirmed cervical intraepithelial neoplasia (CIN) in between December 1995 and December 2000 and subsequently delivered (after 20 weeks gestation) at the University Hospital of Northern Norway. Women who had an ectopic pregnancy or an abortion (spontaneous or induced) following LEEP were excluded from analysis. Two controls matched for the date of delivery, age, parity, previous obstetric history and smoking habit were identified for each case using routinely entered data from the birth register. The main outcome measures were the duration of pregnancy and birth weight. Other variables recorded included the grade of cervical dysplasia, size of the electrosurgical loop, age, parity, pregnancy complications, mode of delivery, and perinatal outcome. Results: Of a total of 428 women of reproductive age who had LEEP performed during the study period, 89 had a pregnancy after the procedure. Ten women were excluded (three ectopic pregnancies, two induced abortions and five spontaneous abortions) from the study. Data from 79 women whose pregnancies progressed beyond 20 weeks and 158 matched controls were analysed. The mean age at the time of LEEP was 27 (range 19–36) years. The histological diagnosis was normal in 3 (3.8%), CIN1 in 5 (6.3%), CIN2 in 18 (22.8%), and CIN3 in 53 (67.1%) of the cases. Overall, mean gestation at delivery (38.3 vs. 39.1 weeks), mean birth weight (3,412 vs. 3,563 g), prevalence of preterm birth (11.4% vs. 10.8%) and low birth weight (10.1 vs. 5.1%) were not significantly different among the cases and controls. But when a relatively large loop (25 mm) had been used, the risk of preterm delivery (odds ratio 4.0) and low birth weight (odds ratio 14.0) was significantly higher than in controls. Pregnancy complications occurred more frequently (20 vs. 7%; p=0.006) among the cases than the controls. Conclusion: LEEP in women with CIN did not significantly increase the risk of low birth weight or preterm birth in subsequent pregnancy in comparison to their controls, except when the size of electrosurgical loop was relatively large. However, the prevalence of pregnancy complications was significantly higher after LEEP.     

Longitudinal Assessment of Ovarian Perifollicular and Endometrial Vascularity by Power Doppler Ultrasound in Pregnant and Non-Pregnant Cycles in the IVF Setting

Purpose: This longitudinal study aimed to compare ovarian perifollicular and endometrial blood flow (PFBF and EBF, respectively) during the follicular phase in pregnant and non-pregnant IVF cycles.Methods: Serial transvaginal scans were performed in 15 subjects undergoing IVF treatment. Both PFBF and EBF were subjectively graded (grades 0–4 for PFBF and grades 1–3 for EBF). After confirmation of clinical pregnancy, the treatment cycles were grouped into Pregnant and Non-pregnant cycles. Ovarian PFBF and EBF were retrospectively compared between the two groups.Results: In pregnant cycles, the proportion of large (15 mm) follicles with high (2–4) grade PFBF increased with time throughout the follicular phase, and the proportion of large follicles with poor (0–1) grade PFBF decreased. In non-pregnant cycles these trends were reversed. There was no difference in EBF between the two groups.Conclusion: The pattern of ovarian PFBF but not EBF may be predictive of treatment outcome.     

Identifying the Public’s Knowledge and Intention to Use Human Cloning in Greek Urban Areas

Purpose: The understanding of the publics knowledge on human cloning (HC) and its acceptability are considered important for the development of evidence-based policy making. The aim of this research study was to investigate the demographic and socioeconomic variables that affect the publics knowledge and intention to use HC in urban areas of Greece. Additionally, the possible association of religiousness with the knowledge and the intention to use HC were also investigated.Methods Individual interviews were conducted with 1020 men and women of urban areas in Greece. Stratified random sampling was performed to select the respondents. Several scientists, experts in HC, evaluated the content of the instrument initially developed. The final questionnaire was consequently the result of a pilot study.Results Almost half of the respondents (51.5%) believed that HC is a sort of in vitro fertilization and 42.9% that it has already been applied to human being. They were not aware that the cloned fetus grows in the womans uterus (41.5%) and that HC could regenerate human organs (41.7%). The acceptability of human cloning for the cure of terminal diseases and transplantation need is very high (70.7% and 58.6%, respectively). The publics intention to have recourse to cloning on the grounds of bringing back to life a loved person or because of reproductive disorders was reported as desire by 35% and 32.5%, respectively. The occupational category (scientists, self-employed, and artists), the Intention to use HC, and the number of children are highly significant predictors of valid knowledge about HC. Low rates of church attendance appeared to relate with high reported Intention to use HC, and increasing scores of valid knowledge about HC increased the publics Intention to use HC.Conclusions A number of specific demographic and socioeconomic characteristics and high scores of knowledge provide a persuasive justification in demonstrating intention toward HC. The current study suggests that these findings should receive further attention by policymakers and scientists within the Greek context.     

Le Fort’s partial colpocleisis: a review of one surgeon’s experience

Objective To evaluate the success of Le Fortes colpocleisis.Design Retrospective review.Setting Southmead Hospital, Bristol, UK.Methods All women who had undergone a colpocleisis procedure from 1995–2002 at Southmead Hospital, Bristol were retrospectively reviewed.Main outcome measures Satisfaction with operation, recurrence of prolapse, development of urinary incontinence.Results Twenty-seven women underwent Le Fortes colpocleisis during the 7 years. The median length of time of the operation was 35 min; in two of the cohort the operation was performed under local anaesthesia. The procedure was successful in 89% of the women. There was 100% satisfaction in this remaining group. There were no new cases of urinary incontinence.Conclusion Le Fortes colpocleisis is a useful procedure in the management of genital tract prolapse in elderly or medically unfit women. Patient selection is of crucial importance, but this caveat applies to all therapeutic interventions.     

Antenatal corticosteroid therapy in premature infants

Objective The objective was to examine the effect of antenatal corticosteroid treatment on premature infants, with special attention to any possible adverse effects on neonatal outcome.Methods A retrospective chart review of all singleton and multiple pregnancies delivered in our perinatal center between 1991 and 1999, who had a birth weight of 1,500 g and who were subsequently admitted to our neonatal intensive care unit. Three hundred and sixty-five infants were included in the study and divided into two groups. One group had a gestational age below 28 weeks (196 days) and one group was 28 weeks (>196 days) onward.Results Antenatal corticosteroid therapy reduced the duration of mechanical ventilation, the need for supplementary oxygen, and the need for exogenous surfactant in neonates born at >196 dayss gestation (p<0.05). Corticosteroid treatment seemed to benefit the respiratory distress syndrome (RDS; p=0.051) in this group. There were less cases of necrotizing enterocolitis and neonatal death in the group with corticosteroid treatment (p<0.05). Before 28 weeks gestation, all parameters that were examined (e.g., duration of mechanical ventilation, need for supplemental oxygen, need for exogenous surfactant, RDS) showed no significant differences between those pregnancies pre-treated with corticosteroids or those not treated with corticosteroids. There was no adverse effect of corticosteroids on chorioamnionitis and early onset sepsis in pregnancies with a premature rupture of the membranes. Repeated corticosteroid treatment had no effect on birth weight, but did not improve neonatal outcome either. The interval between last corticosteroid treatment and delivery had no influence on RDS. There was no effect of corticosteroids on periventricular leukomalacia and intraventricular hemorrhage. Regression analysis showed a higher risk of severe RDS in multiple gestations.Conclusion Antenatal betamethasone treatment reduces perinatal morbidity and mortality after 28 weeks gestation. We found no adverse effects and also no benefit of repetitive corticosteroid treatment. The interval between last corticosteroid treatment and delivery did not influence the incidence of RDS. Dose, timing, and rate of antenatal corticosteroids should be reconsidered in multiple gestations.     

Infected endometrioma in pregnancy masquerading as acute appendicitis

Background A pregnancy complicated by ovarian endometrioma is rare. Other complications of ovarian endometrioma in pregnancy, i.e., rupture and infection are also rare.Case A 35-year-old woman, gravida 2, para 0-0-1-0, at 35 weeks pregnancy, came to the hospital with a right abdominal pain. She also had a history of diarrhea. She had history of infertility and preexisting right endometrioma. The investigations revealed leukocytosis with neutrophils predominant. The preoperative diagnosis was acute appendicitis. Infected right ovarian endometrioma was demonstrated during exploratory laparotomy, opened and drainage of the right endometrioma and appendectomy were performed. The final diagnosis was infected ovarian endometrioma in pregnancy, later confirmed by a pathological report.Conclusion Although complication of ovarian endometrioma such as infected endometrioma during pregnancy is rare, it should be included in the differential diagnosis of pelvic pain during pregnancy, especially in the patient who has history of ovarian endometrioma.     

Informed consent for endoscopic surgery—myth or reality?

Patients, we are told, expect evidence-based information on which to base their consent if they are to undergo an operative procedure. Much evidence is, however, lacking, and few have any concept of the meaning of risk. This editorial examines this and the risks of diagnostic laparoscopy with a plea for more multi-centre international audits of risk.     

Comparison of laparoscopy versus laparotomy for the surgical treatment of ovarian dermoid cysts

To compare laparoscopy with laparotomy for the surgical management of ovarian dermoid cysts, a retrospective analysis of data of 108 patients who had surgery at our institution from January 1998 to August 2001 was performed. The surgical data of these patients were obtained from a computerized data base. The following data were abstracted: the patients demographic features, size of dermoid cysts, spillage rate, estimated blood loss, operative times, duration of hospital stays, and intraoperative or postoperative complications. Statistical techniques included Students t-tests, Fishers exact tests, Mann-Whitney tests, and chi-square analysis. Of 108 patients with dermoid cysts, 53 (49.1%) underwent laparoscopy and 55 (50.9%) had laparotomy. The mean estimated blood loss was significantly less in laparoscopy (71.6±63.5 ml) compared with laparotomy (119.2±101.6 ml). Hospital stay was significantly shorter in the laparoscopy group (0.6±0.8 days) compared with the laparotomy group (2.2±1.0 days). Also, the postoperative complication rate was lower in the laparoscopy group (3.8%) compared with the laparotomy group (14.5%), but the difference did not reach statistical significance. Whereas the laparotomy groups spillage rate of 4.1% and operative time of 86.7±39.6 min were significantly lower than the laparoscopy groups spillage rate of 31.4% and operative time of 118.4±51.5 min, the laparoscopy group had less blood loss, shorter hospital stay, and fewer complications. The laparoscopic management of benign cystic teratomas can be safely performed.Presented at the American Association of Gynecologic Laparoscopists meeting (2001).     

Unilateral renal agenesis associated with ipsilateral blind vagina

Summary Activities of DNA polymerase and were assayed in crude extracts prepared from human placenta. Polymerase activity was high in early pregnancy but low during the 2nd trimester. Polymerase activity did not change significantly with gestational weeks. The increase in polymerase activity in early pregnancy may be closely related to mitosis at the time of placental formation; there might also be some type of accelerating factor for polymerase in early pregnancy.     

Adenomyosis in a patient with mosaic Turner’s syndrome

Background Few case reports describing endometriosis in patients with gonadal dysgenesis have been published, but none has reported the presence of adenomyosis in a patient with Turners syndrome.Case A 31-year-old woman with mosaic Turners Syndrome (45,X/46,XX/47,XXX) was referred to us because of severe iron deficiency anaemia due to hypermenorrhea and persistent lower abdominal pain for more than six months. She presented normal secondary sex development, normal breast, normal pubic and axillary hair. The external genitalia were also normal. Laboratory examination showed normal gonadotropin, 17beta-estradiol, plasma androgens and cortisol levels. At transabdominal ultrasound a myoma (15×8.5×8 cm) arising from the posterior uterine wall was suspected. The mass was removed during laparotomy. Histologic examination confirmed the presence of the myoma and revealed the presence of focal adenomyosis.Conclusion Adenomyosis and leiomyomata are separate entities but they share a common pathology in that they develop primarily in women of reproductive age and their growth is oestrogen dependent. To our knowledge, this is the first case report in the literature of adenomyosis in a woman who had the Turners syndrome.     

Idiopathic facial paralysis (Bell’s palsy) in the immediate puerperium in a patient with mild preeclampsia: a case report

Introduction: Idiopathic peripheral facial palsy is the most common and frequent unilateral cranial neurological disorder characterized by an isolated facial nerve paralysis. Case report: We report a case of an idiopathic facial paralysis (Bells palsy) in the immediate puerperium in a patient with mild preeclampsia and diagnosed fetal IUGR. Additionally, the presence of Bells palsy in the puerperium of the mother of our patient suggests a familiar tendency. Discussion: Every gynaecologist and obstetrician should be aware of this quite uncommon complication during pregnancy and the puerperium. This case report illustrates that Bells palsy can occur in the immediate post-partum after mild preeclamptic symptoms. For these women, a maternal surveillance can be recommended. A fast and accurate diagnosis with a subsequent immediate treatment might be very important in avoiding worsening of the symptoms and therefore improve the recovery prognosis.     

The management of an unusually sited isthmicocervical leiomyoma and a huge prolapsed pedunculated submucous leiomyoma

We present two case studies: an unusually sited isthmicocervical leiomyoma and a huge prolapsed pedunculated submucous leiomyoma of the uterus. Case 1 was a 25-year-old virginal woman with a diagnosis of cervical leiomyoma with symptoms of anemia and menorrhagia. Magnetic resonance imaging revealed a mass impinging on the bladder and rectum. Myomectomy was the selected operation because of the patients age and her desire to preserve fertility, even though the tumors size and location increased the risk of operative blood loss and would make the surgical procedure difficult to perform. The pathological specimen was benign. Case 2 was a 43-year-old patient with a chief complaint of difficulty in voiding plus severe vaginal bleeding. The gynecological examination revealed a necrotic mass that filled the vagina completely and stretched its walls. The sonographic findings were consistent with a pedunculated submucous leiomyoma. Total abdominal hysterectomy and bilateral salpingoophorectomy were performed. The histopathological evaluation was benign leiomyoma of the uterus. Cervical and pedunculated submucous leiomyomas are uncommon and represent a technicosurgical difficulty due to location and huge size. However, in order to regress the complications and improve the patients quality of life regarding desire to preserve fertility, conservative surgical regimens should be chosen.