Berry splenic artery aneurysm rupture in association with segmental arterial mediolysis and portal hypertension

A rare case of berry splenic artery aneurysm (SAA) rupture associated with segmental arterial mediolysis (SAM) and portal hypertension is reported. A 66-year-old woman, diagnosed as having liver cirrhosis and portal hypertension 6 years earlier, suddenly developed a lancinating pain in the upper abdomen and lost consciousness. She recovered consciousness while being transferred to hospital by ambulance. During the investigations, her level of consciousness suddenly deteriorated. Ultrasonography showed a massive intraperitoneal hemorrhage, and she died 5(1/2) h after admission. On gross examination at autopsy it was not possible to find the rupture point of the vessel because the pancreas was embedded in a massive hematoma. However, careful dissection of the pancreatic tail after fixation revealed a berry aneurysm measuring 0.8 cm in diameter in a branch adjacent to the bifurcation in the distal third of the main splenic artery. Microscopic examination detected a rupture of the aneurysm. The histology of the arterial wall proximal to the aneurysm showed typical SAM. In general, berry SAA caused by SAM is rare and unlikely to rupture. The SAA in the present case likely occurred and ruptured due to the combination of SAM and portal hypertension.     

Bcl-2 expression as a novel immunohistochemical marker for ruptured tubal ectopic pregnancy

Programmed cell death by apoptosis occurs in fetal and maternal tissues during early pregnancy and plays an important role during implantation, decidualization, and in fetal development. In the regulation of apoptosis, bcl-2 is one of the central controlling genes, and acts by protecting the cell against apoptosis. It is postulated that invasiveness of ectopic trophoblast towards and through the muscularis zone of the tubal wall consequently leading to tubal rupture might be due to disturbed regulation of apoptosis. By means of immunohistochemistry and a computerized image analysis, bcl-2 immunostaining was localized and quantified in 36 randomly selected paraffin-embedded ectopic trophoblast tissue specimens collected from women undergoing surgery for ruptured (n = 18) and non-ruptured (n = 18) tubal ectopic pregnancies. Immunostaining was found in the villi syncytiotrophoblast in all patients, while the percentage of positive bcl-2 immunostained area (%PA) (P = 0.0009) and staining intensity (P = 0.0042) were consistently greater in the group of ruptured ectopic pregnancies. Including the variables %PA and saturation into a logistic regression model for a probability threshold of 0.5 (<0.5 = non-ruptured ectopic pregnancy, >0.5 = ruptured ectopic pregnancy) to identify tubal rupture, a sensitivity and specificity of 94.4% were found. It is suggested that elevated bcl-2 immunostaining in the syncytiotrophoblast layer reflects unlimited cell survival of ectopic trophoblast and could lead to the establishment of a circulating marker for tubal rupture.     

Spontaneous uterine rupture in the first trimester: a case report

Uterine rupture is one of the most feared obstetric complications affecting the pregnant woman and fetus. Most of the cases have various risk factors and mainly occur during the second or third trimester. However, spontaneous uterine rupture during the first trimester is extremely rare. We experienced a case of spontaneous uterine rupture in a 36-yr-old multiparous woman without definite risk factors. The initial impression was a hemoperitoneum of an unknown origin with normal early pregnancy. Intensive surgical method would be needed for accurate diagnosis and immediate management in bad situation by hemoperitoneum even though a patient was early pregnancy.     

Rupture of pregnancy in the communicating rudimentary uterine horn at 34 weeks

Pregnancy in the rudimentary horn is rare and represents a form of ectopic gestation. Despite advances in ultrasound, prenatal diagnosis remains elusive, with confirmatory diagnosis being made at laparotomy. Because of variable muscular constitution of the wall of the rudimentary horn, pregnancy can be accommodated until late in pregnancy, when rupture occurs manifesting commonly as acute abdomen with high risk of maternal mortality. The rudimentary horn may or may not communicate with the uterine cavity with majority of cases being non-communicating. We present a case of pregnancy in the communicating horn that was difficult to diagnose which ruptured at 34 weeks and a review of literature.      

Case report of ruptured non-communicating right rudimentary horn pregnancy: an acute emergency

Ruptured pregnancy in the rudimentary horn of women who have had a vaginal delivery is rare and unpredictable. However, when undiagnosed, this condition could lead to maternal morbidity and mortality. We report a pregnancy at 19 weeks gestation presented with acute abdomen and hypovolemic shock. She was initially thought to have an intrauterine pregnancy with the provisional diagnosis of a ruptured uterus. Intraoperatively, a ruptured non-communicating right rudimentary horn with ex utero pregnancy was discovered.     

Spontaneous rupture of a functioning adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis, and it can be classified as either a functional or nonfunctional tumor. Affected patients usually present with abdominal pain or with symptoms related to the mass effect or hormonal activity of the tumor. Several cases of spontaneously ruptured nonfunctional adrenocortical carcinoma have been reported, but no case of a spontaneous rupture of functioning adrenocortical carcinoma has been described. We report a functioning adrenocortical carcinoma that spontaneously ruptured during a work-up.     

Fatal splenic rupture in a pregnant woman with hemoglobin C/beta-thalassemia and myeloid metaplasia

Splenic rupture with intraperitoneal hemorrhage is a fatal condition that is rarely encountered during the third trimester of pregnancy; its pathogenetic mechanisms and causes are largely unknown. We report a case of splenic rupture in a pregnant woman that caused the death of the mother and child. The patient was a carrier of double heterozygosis for hemoglobin C/beta-thalassemia. Spleen and liver enlargement due to extramedullary hematopoiesis was found at autopsy. Our data suggest that rare and hidden hematologic disorders should be considered as possible causes of splenic enlargement and rupture during pregnancy.     

Ruptured spleen as a differential diagnosis in ruptured tubal pregnancy

Two cases of traumatic biphasic or secondary splenic rupture are presented to demonstrate the clinical picture of an entity the obstetrician-gynecologist will be encountering more commonly in the future. The signs and symptoms of this condition figured prominently in the differential diagnosis of ruptured tubal pregnancy.     

Posterior uterine wall rupture during labour

Vaginal births after Caesarean section (VBAC) are well-accepted procedures when pregnant women do not have any contra-indications. The possibilities of the uterine dehisence and rupture during VBAC should always be considered. This occurrence is usually related to the previous scar tissue and subsequent risk is acceptable. Nevertheless, rupture that occurs in presumably normal tissue areas of the uterus instead of in scar tissue areas with resultant perinatal death is extremely rare. We present a 31 year old woman who had posterior uterine rupture when she tried VBAC at 38 weeks gestation. During the course of VBAC, she had a smooth labour course without use of any augmentation medication, but her condition was complicated with uterine rupture without any premonitory signal. It resulted in maternal shock and sequentially the death of the newborn 7 days after delivery. By reviewing this case report, we should keep in mind that prompt response to every woman during labour is of paramount importance to avoid repeating the occurrence of uterine rupture, partly because uterine rupture could occur without prominent signals and partly because subsequent dangers seem to be those created by acts of omission. Finally, the benefits and safety of VBAC have not been undermined because this patient is an isolated and extremely rare case.     

Early detection of decreased soluble HLA-G levels in the maternal circulation predicts the occurrence of preeclampsia and intrauterine growth retardation during further course of pregnancy

PROBLEM: Soluble (s) HLA-G1/G5 molecules may potentially affect immune homeostasis during pregnancy. The aim of this study was to determine changes of sHLA-G1/G5 plasma levels throughout normal pregnancy and to assess its predictive value for the occurrence of characteristic gestation-associated diseases during further course of pregnancy. METHOD OF STUDY: sHLA-G1/G5 levels were estimated in plasma samples of 40 non-pregnant women, 291 women throughout normal pregnancy and 236 women affected by different complications. RESULTS: In comparison with non-pregnant women sHLA-G1/G5 levels strongly increased during the first trimenon and then decreased continuously toward term. Non-parametric discriminant analysis showed that women with significantly decreased sHLA-G1/G5 levels in the second trimenon had an increased risk of developing preeclampsia and/or intrauterine growth retardation (IUGR) during further course of pregnancy. However, in the third trimenon, sHLA-G1/G5 levels in affected women did not deviate significantly from those of non-affected women. Surprisingly, significantly increased sHLA-G1/G5 levels were detected in third trimenon women with uncontrollable preterm labor, but not in women with prolonged preterm rupture of fetal membranes. CONCLUSION: For the identification of women with an increased risk of IUGR and/or preeclampsia, measurement of sHLA-G1/G5 plasma levels may be a powerful new tool in prenatal diagnostics.     

Epidemiology of group-B streptococcal carriage in pregnant women and newborn infants.

In a population of pregnant women, the prevalence of group-B streptococcal carriage was relatively low. During the 3rd trimester of pregnancy 5-6% of women haboured group-B streptococci and 8-3% were positive at the onset of labour. Some 42% of women who gave positive cultures in labour had given negative cultures during the 3rd trimester and 19% of women who were positive during late pregnancy were culture-negative in labour. The conversion of culture status observed in these women suggests that carriage may be intermittent or that new acquisition of genital-tract streptococci may occur in late pregnancy. The unpredictability of conversion diminishes the reliability of a single culture taken during the 3rd trimester of pregnancy.     

围产期孕妇生殖道B族链球菌感染和耐药情况及其对妊娠结局的影响

目的 分析围产期孕妇生殖道B族链球菌(GBS)感染情况以及对妊娠结局的影响.方法 收集2014年1月至2017年1月期间在我院进行产前检查的476例35～ 37周孕妇生殖道分泌物,通过实时定量PCR技术以及培养法检测B族链球菌感染情况,对分离培养出的GBS菌株进行药敏试验,并将实时定量PCR检测GBS阳性孕妇按不同治疗方案分为A、B两组,A组孕妇分娩开始即静脉注射敏感性抗生素直至分娩结束,B组孕妇在发现GBS阳性时即口服抗生素7d,其余治疗方法同A组,分析两组治疗方案孕妇妊娠结局.结果 476例孕妇围产期生殖道分泌物经实时定量PCR检测GBS阳性者148例,阳性率为31.1％,细菌培养法检测阳性者38例,阳性率为8.0％.分离培养的38株GBS对青霉素、万古霉素、利奈唑胺、红霉素、左氧氟沙星、克林霉素的耐药率为0％、0％、0％、23.7％、31.6％、52.6％.A组孕妇宫内感染、胎膜早破、早产以及新生儿感染发生率均高于B组孕妇,两组差异有统计学意义(P＜0.05).结论 围产期孕妇生殖道GBS感染发生率高,GBS感染可导致宫内感染、胎膜早破、早产以及新生儿感染等不良妊娠结局发生率增加,GBS感染后采用敏感性抗生素预防治疗可以改善孕妇妊娠结局.     

First trimester uterine rupture and scar pregnancy

Uterine rupture during the first trimester of pregnancy is an extremely rare, but life-threatening cause of intraperitoneal hemorrhage. Up to the knowledge of the authors all reports of first trimester uterine ruptures are related to scar dehiscences following previous cesarean sections or occured in unscarred uteri of multiparous women. In cases of multiparity silent ruptures cannot be precluded, so that the uterus might be scarred during the following pregnancy. In early pregnancy of approximately 4–5 weeks, vaginal ultrasonography may clearly verify a scar pregnancy, but sonographical diagnostic findings may change with the pregnancy progress. In all cases of reported first trimester ruptures in pregnancies with previous cesarean sections or in pregnancies of multiparous women reported in literature, dating scans were performed too late for to preclude pregnancies in the scar. We postulate our hypotheses, that all first trimester uterine ruptures are caused by scar implantation of the trophoblast.     

Spontaneous bilateral cornual uterine dehiscence early in the second trimester after bilateral laparoscopic salpingectomy and in-vitro fertilization: case report.

A bilateral cornual uterine dehiscence is reported, which occurred 14 weeks after in-vitro fertilization (IVF) in a patient having a medical history of previous bilateral salpingectomy via laparoscopy. Uterine rupture is a rare obstetric complication usually occurring during the third trimester of pregnancy within a uterus which has previously undergone an operation. Ectopic pregnancy is a well known complication of IVF. Post-salpingectomy cornual localization with rupture has also been published. Possible causes are discussed and the attention of the counselling physician is directed to the necessary awareness of such a complication in this high risk population. The reported case is an extreme rarity: a similar case has not been previously published in the literature.     

Intra-Amniotic Infection/Inflammation as a Risk Factor for Subsequent Ruptured Membranes after Clinically Indicated Amniocentesis in Preterm Labor

The aim of this study was to determine whether intra-amniotic infection/inflammation (IAI) was associated with subsequent ruptured membranes in women with preterm labor and intact membranes who had a clinically indicated amniocentesis. This retrospective cohort study included 237 consecutive women with preterm labor (20-34.6 weeks) who underwent amniocentesis. The clinical and laboratory parameters evaluated included demographic variables, gestational age, C-reactive protein (CRP) and amniotic fluid (AF) white blood cell, interleukin-6 (IL-6) and culture results. IAI was defined as a positive AF culture and/or an elevated AF IL-6 level (>2.6 ng/mL). The primary outcome was ruptured membranes in the absence of active labor occurring within 48 hours of amniocentesis. Preterm premature rupture of membranes subsequently developed in 10 (4.2%) women within 48 hr of amniocentesis. Multivariate analysis demonstrated that only IAI was independently associated with the ruptured membranes occurring within 48 hr of amniocentesis. In the predictive model based on variables assessed before amniocentesis, only CRP level was retained. IAI is an independent risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor. Prior to amniocentesis, measurement of serum CRP level can provide a risk assessment for the subsequent development of ruptured membranes after the procedure.     

Marfan syndrome, dissecting aneurysm of the aorta, and pregnancy

A patient with the Marfan syndrome died suddenly from aortic rupture and dissection in the early puerperium of her second pregnancy. Although the association of the Marfan syndrome and pregnancy is extremely rare, the case reported here being only the fifth on record, the concurrence of dissecting aneurysm or aortic dissection with pregnancy is more frequent. Furthermore it is accepted that aortic dissection in young women below the age of 40 is more common in the pregnant than those not pregnant. The cause of the enhancing effect of pregnancy is unknown but is thought to be endocrine since the stability of connective tissue can be influenced by hormones, particularly the sex steroids.     

Pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure

BACKGROUND: To evaluate pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure. METHODS: This study conducted at a private advanced endoscopy and assisted reproductive technology centre retrospectively evaluated outcomes of 115 women who had pregnancies subsequent to laparoscopic myomectomy. RESULTS: Of the 217 women followed up, 115 had pregnancies subsequent to a laparoscopic myomectomy. Of 141 pregnancies, there were 87 Caesarean sections, 19 vaginal deliveries, 29 abortions and 6 ectopic pregnancies. There were no incidents of uterine scar rupture in any of these pregnancies. CONCLUSIONS: Uterine rupture during pregnancies following laparoscopic myomectomy is rare following single-layer myometrial closure.     

Ruptured saccular pulmonary artery aneurysm associated with persistent ductus arteriosus.

We report a case of rupture of a saccular pulmonary artery aneurysm with fatal hemopericardium in a 29-year-old man who also had persistent ductus arteriosus with severe pulmonary hypertension. Histologic examination of the pulmonary artery showed cystic medionecrosis similar to that observed in patients with ruptured dissecting pulmonary artery aneurysms. The two types of ruptured aneurysms probably only represent different morphological expressions in the same underlying process in which the main contributory factor is pulmonary hypertension.     

Appendectomy and the risk of tubal infertility

We studied the importance of a history of appendectomy for appendicitis in 279 women with laparoscopically or surgically diagnosed tubal infertility and a control group of 957 fertile women. After controlling for the effects of age, use of an intrauterine device for contraception, a history of pelvic inflammatory disease, and other potential confounding variables, we found that no excess risk of tubal infertility was associated with a simple appendectomy without rupture. However, when the operation was reportedly for a ruptured appendix, the relative risk of tubal infertility was 4.8 (95 percent confidence interval, 1.5 to 14.9) for women who had never been pregnant and 3.2 (95 percent confidence interval, 1.1 to 9.6) for women with one or more previous pregnancies. We conclude that the early diagnosis and treatment of suspected appendicitis in girls and women of reproductive age may reduce the incidence of tubal infertility resulting from the sequelae of a ruptured appendix.     

Thrombotic thrombocytopenic purpura and pregnancy

Thrombotic thrombocytopenic purpura (TTP) is an acute life threatening disorder associated with a deficiency in the enzyme ADAMTS 13. It is diagnosed by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and widespread microvascular thrombosis resulting in organ ischaemia. Approximately 70% of TTP cases occur in women and nearly half of these women are of childbearing age. Pregnancy is a recognised precipitating cause of TTP in between 10‐25% of all cases and includes patients with acquired antibody mediated TTP and congenital TTP, often presenting in adult hood. The availability of ADAMTS 13 assays allows differentiation between congenital and acquired TTP and appropriate treatment plans. There is also a subsequent risk of TTP relapse in women with previous non‐pregnancy related TTP. Presentation may occur at any stage in pregnancy or in the post partum period. This would suggest an hormonal influence as well as the reduction in ADAMTS 13 from the second trimester, related to pregnancy associated increase in Von Willebrand Factor. Differentiation from other pregnancy associated microangiopathies, such as pre‐eclampsia, HELLP (haemolysis, elevated liver enzymes and low platelets) or HUS (haemolytic Uraemic Syndrome) may be clinically difficult, but necessary, in part, because of differences in treatment. HELLP and pre‐eclampsia require delivery and HUS supportive care. TTP requires urgent treatment with plasma exchange (PEX) to attain remission, but also to prevent fetal abnormalities resulting from placental thrombosis. Presented is a review of the literature of pregnancy associated TTP and our experience of treatment of patients who present with TTP during pregnancy and monitoring of women who have had a history of TTP. Positive outcome in pregnancy has been associated with regular monitoring of routine laboratory parameters and ADAMTS 13 activity. All patients maintain low dose aspirin therapy and low molecular weight heparin is started in those women where an increased thrombotic risk is determined. The aim is to optimise implantation and preservation of placental function, especially in women with previous pregnancy loss, as abnormalities of the uteroplacental circulation resulting in insufficiency are established early in the first trimester. A significant reduction in ADAMTS 13 activity or reduction in platelet count below the normal range, PEX is undertaken to prevent any further deterioration. Frank relapse is treated with daily PEX. In women with a congenital TTP phenotype, regular treatment through pregnancy has been successfully undertaken. It is very difficult to devise evidence based guidelines for pregnancy in women with a history of TTP. In our cohort, patients with ADAMTS 13 activity < 5% at presentation in the current pregnancy had a history of TTP precipitated during pregnancy or recurrent TTP episodes, such that the chance of further exacerbation during pregnancy was considered to be high. Indeed, cases 1, 2 and 4 have demonstrated ADAMTS 13 activity < 5% before and after these pregnancies and only case 3 and 5 had further TTP episodes following pregnancy. Therefore the intensive monitoring and treatment was based on the high probability of relapse during pregnancy. Indeed, in Patients with normal ADAMTS 13 activity at the start of pregnancy were continually monitored, but did not have a TTP relapse. In Conclusion: a multidisciplinary approach to pregnancy care with regular monitoring of routine laboratory parameters and ADAMTS 13 activity during pregnancy allows pre‐emptive treatment of patients who are at risk from TTP relapse.