Heterotopic pregnancy following ovulation induction by clomiphene citrate and timed intercourse: a case report

We report a combined intra-uterine and unruptured tubal pregnancy following ovulation induction by clomiphene citrate (CC) and timed intercourse. The diagnosis of heterotopic pregnancy (HP) is the major problem until occurrence of tubal rupture. Because HP is a life-threatening condition, the diagnosis should be made as soon as possible. In a spontaneous conception, HP is a rare event. The risk of HP significantly increases after ovulation induction. Clomiphene itself could be associated with a high HP rate. We present a case with normally developing intra-uterine singleton pregnancy succesfully managed by salpingectomy of synchronous tubal pregnancy following ovulation induction by CC and a review of the literature.     

Acute myocardial infarction in a young woman taking oral contraceptives. A case report

Acute myocardial infarction occurred in a 25-year-old woman. Coronary angiography performed one month after the acute illness was normal. An ergonovine test was negative. The patient's acute myocardial infarction most probably was induced by the use of oral contraceptives in combination with heavy smoking. Oral contraceptives, with their known influence on the blood coagulation system, must be considered a risk factor in precipitating coronary artery disease.     

Epithelioid leiomyosarcoma of the ovary

INTRODUCTION: Leiomyosarcoma of the ovary is a rare lesion usually seen in postmenopausal women. Epithelioid leiomyosarcoma of the ovary is exceptionally rare, with only one previously reported case. CASE: A 42-year-old nulliparous woman undergoing ovulation induction presented with a left adnexal mass. An exploratory laparotomy was performed. Frozen section diagnosis was read as fibrothecoma, and an oophorectomy was performed. The final diagnosis was epithelioid leiomyosarcoma of the ovary. Subsequently, a staging procedure including hysterectomy was performed with no residual disease. DISCUSSION: This is an unusual case for several reasons. Most leiomyosarcomas of the ovary have occurred in postmenopausal women and were of advanced stage at diagnosis. Our case had an epithelioid histology, occurred in a premenopausal woman, and was confined to the ovary. The fact that the patient was undergoing ovulation induction at the time of diagnosis raises the question of the risk of developing ovarian neoplasms with these medications.     

Acute myocardial infarction during the second trimester of pregnancy

Acute myocardial infarction during pregnancy is a very rare event. It occurs from 1 per 10,000 to 1 per 30,000 deliveries. Diagnosis of myocardial ischaemia is difficult because of typical complaints in pregnancy such as breathlessness and pain in chest. Its first recognisable symptom is very often loss of consciousness and cardiac death. We present the case of a 36-year-old woman with cardiac arrest in the second trimester of pregnancy. The defibrillation was applied four times with power ranging from 150 J to 200 J. Acute myocardial infarction was diagnosed on the basis of biochemical and electrocardiological examinations. Pharmacological treatment consisted of adrenalin, lidocaine, dopamine, heparin, insulin and cordarone. Uncomplicated pregnancy and delivery by caesarean section is described. A review of literature follows. CONCLUSION: Although myocardial infarction is a rare complication of pregnancy, it always should be taken in consideration, especially in case of multipara older than 32, suffered from hypercholesterolemia or diabetes, treated with beta-mimetics or ergot alkaloid.     

Recurrent massive hemoperitoneum due to ovulation as a clinical sign in congenital afibrinogenemia

Massive hemoperitoneum due to ovulation is a rare but serious and life-threatening complication for women with coagulation disorders, and may lead to surgical interventions and even oophorectomy. Congenital afibrinogenemia is an uncommon coagulation disorder usually discovered during childhood. Intraabdominal bleeding due to ovulation is very rare in these patients and only a few cases of corpus luteum rupture and hemoperitoneum in afibrinogenemic patients have been described. In all women, the diagnosis was known since childhood. We report on a 24-year-old woman with congenital afibrinogenemia with recurrent massive intraabdominal bleeding due to ovulation as the presenting clinical sign. Exploratory laparotomy and excision of the ruptured follicle was performed at the first bleeding episode; the second episode was managed with fresh frozen plasma and blood transfusions. Conservative management is crucial for these patients. If surgery cannot be avoided, a conservative surgical approach should be chosen to preserve ovarian function.     

A comparison of the effects of clomiphene citrate and the aromatase inhibitor letrozole on superovulation in Asian women with normal ovulatory cycles

OBJECTIVE: To compare the effect of the aromatase inhibitor letrozole and clomiphene citrate (CC) on superovulation in women with normal ovulation. METHODS: A cross-over randomized study of 22 women with normal ovulation, divided randomly into two equal cohorts, was carried out. Each group of 11 women was randomly allocated to take letrozole or CC for one cycle. After washing out for one cycle, the alternative drug was administered in the subsequent cycle. The number and size of mature follicles, endometrial thickness, and estradiol and progesterone levels were monitored. RESULTS: The number of mature follicles and estradiol levels on ovulation day were significantly lower in the letrozole group than the CC group (p < 0.05 for both). However, no differences between the two groups in endometrial thickness and pattern were observed. Progesterone levels showed ovulation in all cycles. CONCLUSIONS: The administration of 50 mg CC on days 3-5 was superior to 2.5 mg letrozole for superovulation induction in women with normal ovulation.     

Isolated prolactin deficiency: a case report.

A 36-year-old woman, with lifelong oligomenorrhea and immeasurable serum PRL levels, conceived and had normal deliveries after ovulation induction with CC. Alactogenesis followed both deliveries. Evaluation of other pituitary hormones were within normal limits, and attempted stimulation of PRL levels by TRH was unsuccessful. The clinical significance of isolated hypoprolactinemia is discussed.     

自然及促排卵周期子宫内膜整合素α4β1的表达

目的 了解氯米芬（CC）、绝经期促性腺激素（hMG）对黄体中期子宫内膜整合素α4β1表达的影响。方法 应用单克隆抗体,采用免疫组织化学技术检测48例正常妇女自然周期以及48例正常妇女、30例多囊卵巢综合征患者应用CC／绒毛膜促性腺激素（hCG）及CC／hMG/hCG方案促卵治疗后黄体中期子宫内膜整合素α4β1的表达。结果 子宫内膜整合素α4β1在正常妇女自然周期着床窗口期呈现强阳性表达,而CC、hMG抑制整合率α4β1的表达,两者比较,差异有极显著性（P＜0．01）;妊娠者较妊娠者整合素α4β1表达强度高。结论 促排卵周期黄体中期整合素α4β1表达下降或缺失,子宫内膜容受性下降,妊娠率降低。     

Takotsubo cardiomyopathy--transient left ventricular apical ballooning mimicking acute myocardial infarction.

Takotsubo cardiomyopathy is characterized by transient left ventricular dysfunction with clinical symptoms of chest pain, electrocardiographic changes of ST-segment elevation or T wave inversion, which mimics acute myocardial infarction in patients without angiographically significant coronary artery stenosis. We report a 75-year-old woman with a history of chest tightness who presented with typical pictures of takotsubo cardiomyopathy. Acute myocardial infarction was initially diagnosed based on the electrocardiographic changes and elevated troponin. Apical akinesis and ballooning with basal hyperkinesis were noted during left ventriculography. Coronary angiography, however, did not show significant coronary artery stenosis. Electrocardiography was normal 3 months later. Follow-up echocardiography did not show any wall motion abnormality. This patient remained well without chest pain or dyspnea over 24 months of follow-up. Optimal medical management of takotsubo cardiomyopathy remains unclear. This patient received diltiazem to prevent possible coronary artery spasm. The prognosis of this syndrome seems to be favorable except for occasional mortality due to left ventricular rupture or ventricular arrhythmia. Recurrence of this syndrome is rare.     

HELLP syndrome, multifactorial thrombophilia and postpartum myocardial infarction

A case of postpartum acute myocardial infarction with intraventricular thrombus occurred in a woman with HELLP syndrome. Since coronary artery disease was ruled out angiographically, the assumed pathophysiological mechanism for myocardial malperfusion was intermittend coronary vasospasm and thrombosis. There were several thrombophilic risk factors detectable (heterozygous factor V Leiden, low levels of antithrombin III, protein S deficiency), whose possible impact in this rare but severe clinical condition is discussed.     

Severe ovarian hyperstimulation syndrome. Case reports

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovulation induction. It is most often associated with the administration of human menopausal gonadotropins (hMG) or purified preparation of follicle stimulating hormone (FSH), but has also been reported after clomiphene (CC) and in patients with hydatiform mole and chorioepithelioma. Moreover, OHSS has been observed in cases of multiple pregnancy unrelated to the use of fertility drugs. In recent years, the hormonal induction of ovulation has been practised to an increasing degree, partly due to the extended use in vitro fertilization (IVF) and gamete intra fallopian transfer (GIFT) techniques in the treatment of infertility. This trend will undoubtedly result in a growing number of patients with OHSS: For this reason, it is important to elucidate the pathophysiological mechanisms responsible for trigging this condition and discuss the treatment possibilities once it has arisen. We will present three patients who developed OHSS after different attempts at ovulation induction. Interestingly, aspiration of the follicles, which was carried out in two of the cases, did not influence the progress of the condition.     

Combined subsequent development of intrauterine and extrauterine gestations

A case of combined subsequent development of intrauterine and extrauterine pregnancy is reported. Signs of normal pregnancy associated with abdominal pains and an adnexal mass were the most significant symptoms and the final diagnosis was verified by laparoscopy in both cases. We consider that drugs for induction of ovulation (chlomiphene citrate and menopausal gonadotropins) were the causative factors of this rare obstetric complication.     

促排卵周期PCOS妇女子宫内膜纤维粘连蛋白及层粘连蛋白的表达

目的:了解促排卵药物氯米酚(CC)、hMG及GnRH-a对黄体中期子宫内膜内膜纤维粘连 蛋白(FN)及层粘连蛋白(LN)表达的影响。方法:应用单克隆抗体,采用免疫组织化学技术检测50 例正常妇女自然周期以及50例正常妇女,45例多囊卵巢综合征妇女应用CC／hCG,CC／hMG／hCG 及GnRH-a／hMG／hCG方案促排卵治疗后黄体中期子宫内膜FN和LN的表达。结果:子宫内膜FN 和LN表达在正常妇女自然周期着床窗口时呈现强阳性;而CC、hMG抑制FN和LN的表达,使 其阳性强度减弱,有显著性统计学差异P<0．01;GnRH-a对FN和LN抑制不明显。同时妊娠者较 未妊娠者FN和LN表达强度高。结论:CC／hCG及CC／hMG／hCG方案促排卵后黄体中期子宫内膜 中FN和LN表达下降或缺失,内膜容受性下降,妊娠率降低。     

多囊卵巢综合征氯米芬抵抗的预测及促排卵治疗

多囊卵巢综合征（polycystic ovary syndrome,PCOS）是无排卵性不孕症最常见的原因,对于有生育要求的PCOS患者,促排卵是其首选治疗方案。枸橼酸氯米芬（clomiphene citrate,CC）是目前国内外指南推荐治疗PCOS不孕症的传统一线促排卵药物,但CC的治疗反应性个体差异显著,其中约40%的患者对CC不反应,即CC抵抗。综述近年来CC抵抗的PCOS患者预测指标及替代的促排卵策略的研究进展,主要从表型、生化特征和基因组学角度阐述PCOS不孕症患者CC抵抗预测指标,从来曲唑（Letrozole,LE）、促性腺激素（gonadotropin,Gn）、腹腔镜卵巢打孔术（laparoscopic ovarian drilling,LOD）、体外受精（in vitro fertilization,IVF）及中医辅助治疗等治疗方式中选用单一或联合的方案阐述其替代促排卵策略,并比较各种方案或方案组合的优势与潜在不足,以期为临床PCOS不孕症患者提供更加精准、个体化的促排卵方案。     

Intrauterine left chamber myocardial infarction of the heart and hydrops fetalis in the recipient fetus due to twin-to-twin transfusion syndrome

A rare complication of twin-to-twin transfusion syndrome (TTTS) is described: myocardial infarction of the recipient fetus. Myocardial infarction and hydrops are considered to be consequences of hypertension in the recipient. No other organs were affected. Pathological signs of intrauterine hypertension were estimated by the thickness of vessel walls and signs of hypertrophied myocardial cells. In the heart of the recipient fetus there was a chronic myocardial infarction near the apex cordis on the anterior wall with an aneurysm 4x5 mm in diameter. Diagnosis was based on light microscopic examination. The poor myocardial systolic function resulted in hydrops. Since the mother was administered beta sympathomimetics in therapeutic doses the contribution of the drug to the myocardial infarction is uncertain, but we would like to suggest this as a possible adverse effect in TTTS. The present case is the first reported myocardial infarction in connection with the syndrome.     

Unexpected pregnancy during hormone-replacement therapy in a woman with elevated follicle-stimulating hormone levels and amenorrhea.

Pregnancy in patients with hypergonadotropic amenorrhea, although previously reported, remains quite rare. Women may conceive spontaneously or following different regimens of ovulation induction, thus indicating that ovarian failure is not always permanent. The case of an 18-year-old woman with premature ovarian failure, who conceived during hormone-replacement therapy, is reported. During hormone-replacement therapy, elevated gonadotropin levels returned to the physiologically normal range. It is suggested that this restored the receptors to luteinizing hormone and to follicle-stimulating hormone, which might have been downregulated. This hypothesis is supported by previous results from clinical trials and experimental work on a rat model.     

Kontrazeption

During treatment with ovulation inhibitors, severe adverse effects are very rare, e.g. venous thromboembolism, myocardial infarction, and stroke. The risk increases in women with a predisposition or risk factors. Healthy, nonsmoking females of normal weight and with nonremarkable family history can be treated with low-dose combined hormonal contraceptives, whereas for patients at risk or contraindications for ovulation inhibitors, other safe and reliable contraceptive methods are available.     

Myocardial Infarction in Pregnancy

Myocardial infarction is a rare complication during pregnancy, with an estimated incidence of one in 10,000 pregnancies. Less than 100 cases have been reported. Pregnancy is associated with profound alterations in the maternal cardiovascular system, making pregnancy in the presence of maternal cardiac disease hazardous. Labour and delivery increase cardiovascular stress. Maternal mortality in pregnancies complicated by myocardial infarction is 35 percent. Delivery within two weeks of infarction, or reinfarction during pregnancy is associated with mortality as high as 50 percent. Perinatal mortality is related to maternal outcome.Clinical management of the pregnant woman with myocardial infarction should be multidisciplinary, involving input from obstetrics, cardiology, and anaesthesia. The goals of management are to decrease cardiac work, prevent extension of infarction, increase oxygenation, and prevent complications. During labour and delivery, adequate analgesia, preferably epidural, is essential. The mode of delivery is controversial, however most authors recommend that Caesarean section be reserved for obstetric indications, with assisted vaginal delivery to shorten the second stage of labour being the preferred method. Cardiac arrest in pregnancy is a rare event, but one for which physicians should be prepared. Perimortem Caesarean section to save the fetus should be considered if maternal resuscitation is unsuccessful. Early recognition of myocardial infarction will facilitate effective management, prevention of complications, and improvement in maternal and perinatal survival.     

Pregnancy induced with menotropins in a woman with polycystic ovaries, endometrial hyperplasia, and adenocarcinoma

A 31-year-old woman is described with PCOD associated with endometrial hyperplasia and well-differentiated adenocarcinoma. Conservative treatment with ovulation induction was pursued for a total of 3 1/2 years. After CC treatment failed to achieve conception, treatment with menotropins resulted in a twin pregnancy that aborted spontaneously and a singleton term pregnancy. Hysterectomy was performed 4 1/2 years after the initial diagnosis of well-differentiated endometrial adenocarcinoma was made. Histologic examination of the endometrium showed no progression of the disease. Ovulation induction of patients with polycystic ovaries and well-differentiated and noninvasive endometrial adenocarcinoma may be justified in properly selected cases.     

Adult-onset idiopathic hypogonadotropic hypogonadism and pregnancy in a 35-year-old woman: a case report

BACKGROUND: Idiopathic hypogonadotropic hypogonadism (IHH) is a rare condition characterized by low gonadotropin production, absent or incomplete puberty and absence of a central nervous system tumor. An adult-onset form of IHH has been found previously only in men. CASE: A 35-year-old woman completed puberty and experienced monthly menstrual cycles for 5 years before developing hypogonadotropic secondary amenorrhea that lasted for 17 years. Clinical evaluation failed to explain her prolonged hypogonadotropic amenorrhea, and successful pregnancy was completed following induction of ovulation with exogenous gonadotropin therapy. CONCLUSION: This case may represent an extreme of the phenotypic spectrum of IHH that has been previously reported to occur in men only. In gonadotropin-sensitive women, pregnancy may be achieved with administration of exogenous human menopausal gonadotropins or with gonadotropin-releasing hormone by infusion pump.