Post-partum sacral fracture associated with heparin treatment

We report the case of a 19-year-old woman who consulted for low-back pain 3 weeks after her first delivery. This young woman had a personal history of protein C deficiency and was treated daily during her pregnancy with low-molecular-weight heparin. Her body mass index was 34 and she only gained 10 kg during her pregnancy. Since the delivery - which occurred without any complication - she had suffered from a gradually increasing right-buttock pain and limp. Magnetic resonance imaging (MRI) revealed a fracture of the right sacral ala. After analgesia and 1 month of home relative bed rest, the patient recovered her functional capacities. Regarding our patient, who had no potential clinical risk factors for osteoporosis, the causal effect of heparin is thus possible but not certain. This case report illustrates the fact that clinicians should have a high suspicion of pelvic fracture in post-partum women, even in very young ones, presenting sudden onset of low back and pelvic pain, especially when they have received heparin during pregnancy. MRI seems to be the key exam because it is able to detect and stage fractures or microfractures.     

Transitory bone marrow oedema of the hip in pregnant patient with antiphospholipid syndrome: A case report

BackgroundTransient bone marrow oedema (BMO) of the hip presents with pain, is diagnosed by magnetic resonance imaging (MRI), and usually resolves within 6 months. Risk factors include pregnancy. Avascular necrosis of bone and an association with BMO are among the less common presentations of antiphospholipid syndrome (APS).Aim of the workTo present a young Croatian female APS patient who developed transient BMO during pregnancy which spontaneously resolved postpartum.Case reportAfter developing left leg deep vein thrombosis and positive lupus anticoagulant at 22 years old, the patient was diagnosed with primary APS. Antinuclear antibody was borderline, but classification criteria for SLE were not fulfilled. She had an early missed abortion during her first pregnancy while receiving low-weight molecular heparin (LWMH) (enoxaparin 40 mg), and her second pregnancy was to term with LWMH, aspirin, and hydroxychloroquine 200 mg daily. During the third trimester of this pregnancy, she developed excruciating bilateral hip pain to the point she could barely walk. Based on an MRI scan, the patient was diagnosed with bilateral BMO of the femoral head. The condition improved and resolved within four months with conservative treatment postpartum, as confirmed by followup MRI.ConclusionConsidering that pregnancy and APS are risk factors for BMO, both played a role in the development of BMO and the severity of presentation. This case report presents a differential diagnosis of hip pain in pregnant patients, especially with APS. Although APS is commonly associated with AVN, it may also be associated with transient BMO.     

Puerperal ovarian vein thrombosis: two case reports

Ovarian vein thrombosis (OVT) is an uncommon but potentially serious complication in the early postpartum. Two case studies seem to prove the point: Case 1 A 24-year-old woman was transferred to our hospital with the chief complaint of abdominal pain radiating to the right thigh, vomit, diarrhea, and a slight pyrexia (37.6 °C rectal). Five days earlier, she had a spontaneous vaginal delivery after labor induction. The woman appeared slightly distressed because of pain; vital signs were found to be normal and the CRP elevated (129.9 mg/L). Abdominal examination was remarkable for tenderness by palpation in the right lower quadrant with no rebound tenderness or guarding. Pelvic examination was remarkable for mild right adnexal tenderness. Abdominal–pelvic computer tomography with contrast medium revealed a 2.5-cm OVT having extended into the inferior vena cava for 14 cm with a slight peripheral edema. The patient was treated with nadroparin 0.6 cc (5700 IU) bid and warfarin 5 mg since the attainment of the therapeutic INR range. Case 2 A 31-year-old twin-pregnant woman had an emergency cesarean section at 35 gestational weeks because of hypertension complicated by increased liver enzymes, diuresis contraction, and continuous lower back pain bilaterally radiating to the groins. One day after delivery, CT scan that was performed because of onward anemia showed a pelvic, perihepatic, and perisplenic blood effusion, and a 1-cm right OVT extended to the inferior vena cava below renal veins for 28 mm. She underwent exploratory laparotomy and blood transfusion, and because of respiratory insufficiency she was transferred to a second level center with ICU facility, where she was placed under a suprarenal inferior vena cava filter, and AngioJet Rheolytic Thrombectomy for acute pulmonary embolism was performed.     

Sudden death due to bilateral pulmonary thromboembolism in a patient with multiple myeloma: an autopsy case report]

We encountered a patient with multiple myeloma who died suddenly, in whom bilateral pulmonary artery thrombosis was found at autopsy. The patient was a 50-year-old woman who had received chemotherapy for multiple myeloma at a local clinic for 4 years, and was transferred to our hospital because of recurrence of multiple myeloma in August 1990. Despite chemotherapy performed after admission, serum globulin level increased and her low back pain worsened, and she was generally restricted to bed. On October 21, she developed sudden dyspnea, became markedly cyanotic, lost consciousness, and then suffered a cardiopulmonary arrest. Autopsy revealed bilateral pulmonary artery thrombosis as well as thrombosis in the pelvic veins. Hyperviscosity due to multiple myeloma and long-term recumbency were the probable causes of pelvic venous thrombosis and subsequent pulmonary artery thrombosis. We report a rare case of bilateral pulmonary artery thrombosis which developed during the course of multiple myeloma and led to sudden death.     

Anticoagulation in pregnant women after artificial heart valve replacement: is low-molecular-weight heparin an alternative?

We report on the case of a 24-year-old pregnant woman with acute mechanical mitral valve thrombosis due to a treatment failure of low molecular weight heparin (LMWH) for permanent anticoagulation following mechanical valve replacement. Initially, our patient was put on oral warfarin for anticoagulation, but when her pregnancy was perceived the anticoagulation regimen was switched to daily subcutaneous administration of LMWH in order to minimize the risk of warfarin-induced embryopathy. During her 24th week of gestation she developed acute life-threatening pulmonary edema and hemodynamic instability, which was caused by an acute thrombosis of her artificial mitral valve. In an emergency operation the thrombozed valve was replaced by a porcine biological heart valve. The patient recovered uneventfully and gave birth to a healthy child in her 35th gestational week by cesarean section. In addition we discuss the rationale of different anticoagulation regimens with regard to maternal and fetal outcome with special consideration of LMWH as an alternative strategy to oral anticoagulation during pregnancy in women with mechanical heart valves.     

Spontaneous multiple insufficiency fractures after pelvic abscess and sepsis in a rheumatoid arthritis patient treated with high-load corticosteroid therapy: a case report

We report the unique occurrence and treatment of spontaneous multiple insufficiency fractures after sepsis in a patient with rheumatoid arthritis (RA). The patient was a 53-year-old woman with a 13-year history of RA. Her disease activity was not influenced by a disease-modifying antirheumatic drug (DMARD) regimen that included bucillamine, d-penicillamine, gold, sulfasalazine, and methotrexate. Due to an increased disease activity, her DMARD treatment regimen was changed to leflunomide. She had also undergone corticosteroid therapy with prednisolone ranging from 10 to 15 mg daily over the previous 8 years. She first presented with a wound infection at the surgical site of resection arthroplasty on her left foot, which had caused hematogenous dissemination that led to pelvic abscess and sepsis. For the next 2 years, she experienced multiple insufficiency fractures in parts of the ilium, sacral body, sacral ala, three thoraco-lumbar vertebral bodies (T12, L1, and L2), and subcapital femoral neck without low energy trauma. Postmenopausal osteoporosis, pelvic abscess, sepsis, decreasing daily activity, high RA disease activity, and high-load corticosteroid therapy were considered to be the causes of these fractures. Nonspecific symptoms such as low back pain and fever delayed diagnosis, which may have led to secondary fractures. Although her course after treatment was satisfactory during the study period, we recommend taking repetitive radiographs to detect insufficiency fracture for RA patients with continuing pain and reducing the corticosteroid dose to prevent infection and fracture.     

Prise en charge de l’acromégalie évolutive au cours de la grossesse

Pregnancy in acromegalic patients is an infrequent event, due to perturbed gonadotroph function. On the other hand, pregnancy may cause an enlargement of the adenoma or an increase of growth hormone (GH) secretion. We report the case of a 26-year-old woman with a GH-secreting pituitary macroadenoma who was operated by transphenoidal approach. After surgery, she had a persistant acromegaly due to an intrasellar tumour. She was treated by lanreotide. After one year, the patient had married and became pregnant. Lanreotide was stopped when the diagnosis of pregnancy was established. The follow-up of this patient showed a progressive increase of IGF1 level during pregnancy without tumoral syndrome or visual troubles. No metabolic complication was detected. The patient went to term and gave birth to a healthy baby. In postpartum, the IGF1 level was normal, but the brain MRI revealed a 10 mm intrasellar tumour. The pituitary adenoma was not significantly enlarged during pregnancy. Therefore, pregnancy doesn’t influence acromegaly in young women well controlled by medical treatment.     

Ulcerative colitis case beginning during pregnancy in a patient with antiphospholipid antibody syndrome.

It is well known that there may be an increased tendency for thrombosis in inflammatory bowel disease (IBD). This study presents a case with antiphospholipid antibody syndrome with ulcerative colitis diagnosed during pregnancy. A 30-year-old female patient, in her 6th week of pregnancy, applied to our clinic with complaints of abdominal pain and bloody diarrhea. She had a history of three abortions. She had been given aspirin and heparin treatment due to high levels of anticardiolipin antibody (ACA) in previous examinations that led to the diagnosis of antiphospholipid antibody syndrome. As the left colonoscopic examination of the patient showed ulcerative colitis, aspirin treatment was replaced with mesalazine (750 mg/day, in 3 equal doses). There was a significant relief in complaints of the patient. Medical treatment was interrupted three days before delivery. The patient delivered a baby, at full-term, of 3.6 kg by cesarean section. No adverse effects were observed in the mother or the baby due to the medical treatment. After delivery, mesalazine treatment was restarted. This case is interesting due to the co-diagnosis of IBD in a pregnant woman with antiphospholipid antibody syndrome. Successful and uncomplicated treatment of the patient with mesalazine should also be noted.     

Functioning gonadotroph adenoma with severe ovarian hyperstimulation syndrome: A new emergency in pituitary adenoma surgery? Surgical considerations and literature review

The authors reported 2 cases of functioning gonadotroph pituitary adenoma (FGPA) revealed by an ovarian hyperstimulation syndrome (OHSS) in young women. In the first case, OHSS was observed after GnRH analog injection. Pelvic echography revealed multiple voluminous ovarian cysts. Dopamine agonist posology failed in estradiol hypersecretion control, which necessitated endoscopic endonasal transsphenoidal surgery. The patient experienced improvement in pelvic pain as estradiol hypersecretion decreased during the first few postoperative days. Outcome was favorable, and her menstrual cycle was normal after two months. The second case was a young girl with spontaneous pelvic pain and elevated plasma FSH and estradiol levels. FGPA was confirmed on cerebral MRI. Dopamine agonists were introduced, and surgical removal of the pituitary tumor was scheduled for 7 days later. In the meantime, the patient was admitted and underwent surgery for bilateral adnexal torsion related to OHSS. The pituitary tumor was removed one week later. Outcome was favorable, and estradiol and FSH plasma levels were normal after 3 months. The ovarian cysts were no longer visible on echography after 3 months. Given the lack of efficacy of the current standard medical therapy, surgical removal of pituitary adenomas is the reference treatment for FGPA. The authors suggest that severe OHSS related to FGPA should be considered as a relative surgical emergency and that surgery should not be unduly delayed, given the unpredictable risk of adnexal torsion, particularly in case of voluminous ovarian cysts. The authors performed a literature review on this topic.     

Chronic pelvic girdle relaxation

A 24-year-old pregnant woman presented with severe pain in her symphysis pubis and right buttock. The iliac gapping test evoked pain in the right sacroiliac joint and symphysis pubis. The iliac compression test evoked pain in the symphysis pubis. The Patric test evoked pain in the symphysis pubis and right sacroiliac joint. Radiographs of the pelvis showed no abnormality except for a 7 mm separation of the symphysis pubis and mild bilateral acetabular dysplasia. Four and a half years later and 12 weeks into her next pregnancy she again complained of moderate pain in the symphysis pubis. Computed tomography, magnetic resonance imaging and bone scintigraphy using^99mTc MDP showed no abnormality in the pelvis and spine. Laboratory data were normal. An injection of steroid and lidocaine into the right sacroiliac joint dramatically improved the pain. Eight years after first delivery she could walk independently, but often complained of mild to severe pelvic pain which was relieved with non-steroidal anti-inflammatory drugs.     

Complete resolution of a mitral valve vegetation with anticoagulation in seronegative antiphospholipid syndrome

Antiphospholipid syndrome (APS) is a disorder characterized by recurrent venous or arterial thrombosis and/or fetal loss; involvement of cardiac valves is also seen. A seronegative variant has been described previously. We report a case of a woman with recurrent pregnancy loss, prior strokes, and a negative workup for known antiphospholipid antibodies. During her current pregnancy, she presented with acute stroke and mitral valve vegetation. Her workup for antiphospholipid syndrome and other thrombophilias remained negative even after the stroke. Her mitral valve vegetation resolved completely with aspirin, heparin, and warfarin. We believe this to be the first report of complete resolution of valvular vegetation with antiplatelet and anticoagulant therapy alone in a patient with seronegative antiphospholipid syndrome. Moreover, this appears to be the first report of stroke associated with this condition.     

Learning on the Web. Case 9: a mother's heartache

A 35 year old white woman presented with chest pain and breathlessness 10 days following an elective caesarean section. This was her second pregnancy, which had proceeded to term without complications. Up until then, she had been completely fit and well. Her ECGs were found to be abnormal, and the ultrasound study of her heart gave serious cause for concern. This interactive case report charts the evolution of the patient's clinical course and provides concise and up-to-date literature reviews on two cardiac conditions that share a predilection for women in the peripartum period.     

Dyskinesia associated with hyperglycemia and basal ganglia hyperintensity: report of a rare diabetic complication

The syndrome of dyskinesia associated with hyperglycemia and basal ganglia hyperintensity on T1 – weighted MR images is rare and most often affects elderly patients with type 2 diabetes. We report a case of a 79 year-old female patient who presented to the ED with a 12 h history of a left sided hemichoreoathetosis. Laboratory results revealed pronounced nonketotic hyperglycemia [27 mmol/L (486 mg/dL); HbA1c 140 mmol/mol (15 %)] and brain MRI showed bilateral T1 hyperintensity in the basal ganglia, more noticeable on the right side. One week before she had been admitted with a diagnosis of transient ischemic attack consisting in left hemiparesthesia, also with nonketotic hyperglycemia [38.9 mmol/L (700 mg/dL)] and was discharged home with partial correction of her metabolic disturbance. The movement disorder did not improve with adequate glycemic control so haloperidol was started. Six weeks later she was seen on an outpatient basis. She still had minimal residual involuntary movements of the left arm and leg. Laboratory exams revealed a well controlled diabetes mellitus [glycemia 6.0 mmol/L (109 mg/dL), HbA1c 57 mmol/mol (7.4 %)]. In conclusion, the syndrome of dyskinesia associated to hyperglycemia and hyperintensity in the basal ganglia on T1 – weighted MR images is a rare, intriguing and yet incompletely understood complication of diabetes mellitus. The increasing number of reported cases may help to better understand its peculiarities such as the existence of a clear clinical radiological dissociation and to unveil pathophysiological aspects. We suggest the possibility that the metabolic disturbances unmask a previous established asymptomatic striatum vasculopathy.     

Exzessive Hyperchylomikronämie – eine seltene Ursache für akuten Thorax- und Oberbauchschmerz in der Schwangerschaft

CASE REPORT: A 24-year-old woman in her 13th gestational was admitted to our department with acute retrosternal and epigastric pain. She had been transferred from the gynecologic department where she was treated for vaginal bleeding because of abortus imminens. A cardiac cause was excluded by ECG and echo. Clinical chemistry and abdominal ultrasound confirmed the diagnosis of acute pancreatitis. The woman was known in our outpatient department for hyperchylomicronemia and had already had an earlier episode of acute pancreatitis under oral contraception years ago. At current admission, triglycerides were 11,500 mg/dl. To reduce plasma triglycerides, selective lipid apheresis was performed. Apheresis was well tolerated, and the patient became free of pain within the first 30 min of treatment. Triglycerides decreased to 6,600 mg/dl at this session. Keeping to a low-fat diet (< 30 g fat per day), the patient remained healthy and completed pregnancy with the delivery of a healthy girl in her 39th week of pregnancy. CONCLUSION: Selective lipid apheresis is a safe and effective option in the treatment of hyperlipidemic pancreatitis, even in pregnant patients.     

Chronic pelvic girdle relaxation

Abstract

A 24-year-old pregnant woman presented with severe pain in her symphysis pubis and right buttock. The iliac gapping test evoked pain in the right sacroiliac joint and symphysis pubis. The iliac compression test evoked pain in the symphysis pubis. The Patric test evoked pain in the symphysis pubis and right sacroiliac joint. Radiographs of the pelvis showed no abnormality except for a 7 mm separation of the symphysis pubis and mild bilateral acetabular dysplasia. Four and a half years later and 12 weeks into her next pregnancy she again complained of moderate pain in the symphysis pubis. Computed tomography, magnetic resonance imaging and bone scintigraphy using^99mTc MDP showed no abnormality in the pelvis and spine. Laboratory data were normal. An injection of steroid and lidocaine into the right sacroiliac joint dramatically improved the pain. Eight years after first delivery she could walk independently, but often complained of mild to severe pelvic pain which was relieved with non-steroidal anti-inflammatory drugs.     

Thyroid-stimulating antibodies and thyroid stimulation-blocking antibodies during the pregnancy and postpartum period: a case report.

This report describes a unique pattern of changes in thyroid function and thyroid antibodies in a woman during the course of two pregnancies and two postpartum periods. A 25-year-old woman developed hypothyroidism in the postpartum period after the delivery of her first child. She was found to have potent thyroid stimulation-blocking antibodies (TSBAb) in the serum. One year later, she became pregnant again, and during the pregnancy, TSBAb had decreased to an undetectable level. She gave birth to the second healthy child and developed postpartum thyrotoxicosis, probably due to destruction of the thyroid gland, which gradually resolved. In this postpartum period, serum TSBAb levels increased. Eight months postpartum, she developed what appeared to be Graves' disease with an elevated 123I-thyroid uptake. Serum thyroid-stimulating antibodies (TSAb) were found at that time, and the TSBAb had disappeared from her serum.     

Warfarin treatment during pregnancy: a clinical note.

The case history is presented of a woman aged 38 who received warfarin treatment because of a mitral valve replacement. During the first trimester of pregnancy, her prothrombin time was 20% of normal and kept at 40% until the 38th week of gestation. Then the patient received heparin until a few days after delivery of a normal child.     

Severe abdominal pain associated with allergic reaction to nafamostat mesilate in a chronic hemodialysis patient

A 33-year-old woman was referred from an outside dialysis clinic to our hospital because of severe abdominal pain during hemodialysis. She had been on chronic hemodialysis for the past 11 years due to chronic glomerulonephritis. Nafamostat mesilate was used as an anticoagulant for hemodialysis, because it was during her menstrual period with hypermenorrhea. On admission, she had no abdominal pain or gynecological abnormalities. On the second day, she had similar abdominal pain during hemodialysis with nafamostat mesilate in our dialysis unit. The abdominal pain disappeared within 60 minutes after discontinuing the hemodialysis. We re-started dialysis using heparin instead of nafamostat mesilate and she had no symptoms. The titer of total immunoglobulin E was high. The drug lymphocyte stimulation test was positive for nafamostat mesilate and antigen specific immunoglobulin E to nafamostat mesilate was highly positive in her blood. Although an allergic reaction to nafamostat mesilate is a rare complication, it should be one of the differential diagnoses of abdominal pain occurring during hemodialysis.     

Successful treatment of a patient with primary Sjögren's syndrome complicated with pericarditis during pregnancy

A 35-year-old woman with primary Sj?gren's syndrome (pSS) developed fever and chest pain during pregnancy. When the dose of prednisolone was reduced, she experienced chest pain with elevated CRP and D-dimer, resulting in admission to our hospital with marked cardiomegaly and pleural effusion. Because there was no evidence of other autoimmune disorders or infection, oral prednisolone was increased to 30 mg daily with heparin, and hypercoagulopathy was carefully monitored. The patient's condition improved rapidly, and she delivered a healthy baby. This is the first case to support the beneficial effect of prednisolone in pericarditis with pSS, and illustrates its safety during pregnancy.     

A rare presentation of appendiceal diverticulitis associated with pelvic pseudocyst

We report a case of a 32-year-old woman with episodic right lower quadrant abdominal pain. With the diagnosis of either acute appendicitis or tubo-ovarian abscess, she was treated with antibiotics, which successfully relieved the pain and the inflammatory findings. She repeated the clinical condition a few times and antibiotics worked each time. In a year, her subjective symptoms became milder, however, a giant pelvic cyst appeared. She had an exploratory laparotomy to confirm this diagnosis. Histopathological studies revealed herniated appendiceal mucosa through the muscular layer associated with chronic inflammation and marked fibrosis. Gynecological disorders such as endometriosis or lutein cyst rupture was denied. These findings represent appendiceal diverticulitis. We discuss the clinical features of the disease and its relation with the pelvic pseudocyst.