Ventral hernia with uterine rupture after vaginal delivery

ObjectiveVentral hernia is uncommon during pregnancy and is extremely rare in postpartum women. It leads to a life-threatening emergency.Case reportA 33-year-old woman, gravida 2 para 1, was admitted to our institute with severe abdominal pain and overdistended abdomen immediately after a full-term vaginal delivery. She had a normal prenatal course and denied having any medical and surgical history. The primipara woman with no history of abdominal surgery was diagnosed with a ventral hernia with uterine rupture after vaginal delivery. We performed an emergency laparotomy and primary repair of the uterine rupture and abdominal wall defect. An abdominal binder was provided for the postoperative period. The patient's postoperative period was uncomplicated. She was discharged from the hospital after 12 days.ConclusionIf a patient has hernia-related symptoms or complications, the diagnosis and management of the hernia should be performed as soon as possible, regardless of the onset, to decrease maternal and fetal mortality.     

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.     

Genital Hair-Thread Tourniquet Syndrome

BackgroundHair-thread tourniquet syndrome is a rare disorder that occurs when a hair or other fiber becomes wrapped around an appendage, resulting in swelling, pain, or even loss of the appendage. Some cases affecting the female genitals have been reported.CaseThe case of a 10-year-old girl with a 3-day history of genital pain is presented. During examination, a hair tourniquet was found at the base of a swollen and painful clitoris. The hair was removed under deep sedation, producing immediate relief.Summary and ConclusionThe most important concern in genital hair-thread tourniquet syndrome is a high index of suspicion and prompt resolution in order to save the affected tissue. It should be considered on the differential diagnosis for all girls with vulvar swelling and indication of pain.     

Long QT Syndrome in Pregnancy: Are Vaginal Delivery and Use of Oxytocin Permitted? A Case Report

BackgroundPatients with congenital long QT syndrome (LQTS) are at increased risk of ventricular arrhythmia, particularly during labour and the puerperium.CaseA 28-year-old primigravida with known LQTS underwent induction of labour at 41 weeks’ gestation using a Foley catheter balloon and IV oxytocin. Vaginal delivery with passive second stage and outlet forceps was undertaken with early epidural analgesia to prevent tachycardia and psychological stress. The patient gave birth to a healthy female, and had an uncomplicated postpartum period under continuous electrocardiogram monitoring.ConclusionVaginal delivery with use of oxytocin for the induction of labour can be safely undertaken in patients with LQTS.     

Postpartum coronary artery dissection followed by heart transplantation

A rare case of coronary artery dissection was observed in a 33-year-old woman on the fourth postpartum day. The ischemic syndrome was followed by aneurysmal dilatation of the left ventricle and progressive heart failure that necessitated cardiac transplantation. The patient is alive and well 3 years after the transplantation.     

Ovarian Hyperstimulation Syndrome Complicating Spontaneous Molar Pregnancy: A Case Report and Review of the Literature

BackgroundOvarian hyperstimulation syndrome (OHSS) is traditionally associated with fertility treatments and results in elevated human chorionic gonadotropin (βhCG) levels and fluid shifts to extravascular compartments. Rarely, spontaneous pregnancies with significant βhCG elevations, such as molar pregnancies, can give rise to OHSS.CaseA 24-year-old woman was diagnosed as having a molar pregnancy at approximately 12 weeks gestation following spontaneous conception. Her initial βhCG was over 1 million IU/L. There was no evidence of metastatic disease. She underwent an uncomplicated dilation and curettage. Three days later, she presented with chest pain, shortness of breath, and abdominal discomfort. Massively enlarged ovaries were identified with bilateral pleural effusions requiring repeated thoracentesis.ConclusionThis case demonstrates rare sequelae of molar pregnancy. Treatment is mainly supportive, and close observation is required to manage complications. In patients with extremely elevated βhCG levels, clinicians must remain vigilant for signs suggesting OHSS, even following evacuation of the uterus.     

Hemodynamic changes during pregnancy and postpartum: a prospective study using thoracic electrical bioimpedance

Objective.?To describe hemodynamic changes in normal pregnancy and postpartum by means of thoracic electrical bioimpedance (TEB).

Methods.?Eighteen healthy pregnant women were included in the study. Eight different hemodynamic variables were measured by thoracic electrical bioimpedance, from 12th week of gestation until 6th month of postpartum period. Data along pregnancy and postpartum were analyzed with SAS statistical software to compare the different values, so normality curves are reported.

Results.?Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and peripheral vascular resistances (PVRs) seem to significantly decrease until 24th week of gestation, and then they seem to increase until delivery, recovering normal values gradually during postpartum period. End-diastolic volume (EDV), systolic volume (SV), cardiac output (CO), and ejection fraction (EF) seem to decrease until 48?h after delivery; statistical significance was found.

Conclusions.?Thoracic electrical bioimpedance may be the most appropriate and accurate technique to measure normal hemodynamic changes during pregnancy and postpartum.     

Streptococcal Toxic Shock Syndrome After Insertion of a Levonorgestrel Intrauterine Device

BackgroundThe insertion of intrauterine devices (IUDs) is associated with a small increased risk of pelvic inflammatory disease and ascending infection, particularly in patients with risk factors. However, the risk of sepsis and toxic shock syndrome after insertion of an IUD is a rare event, described only through case reports in the literature.CaseThis report describes the case of a 40-year-old woman who presented with high fever, myalgias, and abdominal pain 2 days following the insertion of a levonorgestrel-releasing IUD. She was found to have group A Streptococcus infection in the vagina that led to a diagnosis of streptococcal toxic shock syndrome and required admission to the intensive care unit.ConclusionToxic shock syndrome is a rare but potentially catastrophic complication after the insertion of an IUD. Health care providers should be conscious of this complication, particularly among patients presenting with fever and sepsis soon after IUD insertion.     

Dolor pélvico en mujeres con episiotomía versus mujeres con desgarro perineal de segundo grado

IntroductionPelvic pain is one of the most common pelvic floor dysfunctions in the postpartum period, depending on the degree of injury and the time at which it is assessed. The degree of involvement of a mediolateral episiotomy is similar to that of a second degree perineal tear, therefore it was decided to conduct a study to collect the degree of pain reported using the McGill Pain Questionnaire.Material and methodsAn observational, prospective longitudinal epidemiological study of dynamic cohorts was conducted among 384 women, of whom 255 had a second-degree tear and 129 had undergone an episiotomy. An assessment of the pelvic floor was carried out, together with data collection (performance or not of perineal massage, pelvic floor muscle exercises, presence of Kristeller, type of suture) as well as the degree and type of pain using the McGill Questionnaire, in the immediate puerperium, at six weeks, and six months of postpartum.ResultsIn the immediate puerperium more than 50% of women reported some type of painful sensation, without finding significant differences between both cohorts. However, as the study evolved, there was a progressive decrease in pain in both cohorts. By six weeks postpartum, less than 33% of women reported a painful sensation, considered as absence of pain according to the criteria of the McGill questionnaire.ConclusionThe presence of episiotomy or second degree perineal tear was not related to perineal pain.     

Fetal Dilated Cardiomyopathy Associated With Variants of Uncertain Significance in MYH7 and DSG2 Genes: A Case Report and Review of the Literature

BackgroundFetal dilated cardiomyopathy (DCM) is an uncommon prenatal diagnosis associated with significant morbidity and mortality.CaseThis report describes a patient with a diagnosis of fetal DCM at 31⁰ weeks gestation, several weeks after a maternal flu-like illness. Spontaneous improvement was noted on serial echocardiograms. Maternal Coxsackievirus B titers were significantly elevated at 1:80, although post-natal cord blood test results were negative. Genetic panel testing for DCM demonstrated two heterozygous variants of uncertain significance in the MYH7 and DSG2 genes. Although an early post-natal echocardiogram demonstrated a normal left ventricular ejection fraction, right ventricular dysfunction was noted with subsequent cardiac decompensation requiring temporary inotropic support. An echocardiogram at the age of 2 years confirmed normal biventricular function.ConclusionThe finding of fetal DCM should trigger a broad evaluation. In the setting of limited fetal cardiac reserve, the significant hemodynamic changes that occur post-natally may trigger additional decompensation. Clinicians should be aware of the prognostic value of right ventricular function, as measured by fractional area change, in addition to the limitations of serologic and genetic testing.     

Mallory-Weiss Tear Diagnosed in the Immediate Postpartum Period: A Case Report

BackgroundMallory-Weiss tears occur rarely during pregnancy, labour and delivery, and the puerperium, despite the increased frequency of retching and vomiting.CaseWe describe a Mallory-Weiss syndrome diagnosed during the immediate postpartum period in a 34-year-old primigravida. The syndrome initially manifested as lower gastrointestinal bleeding and melena.ConclusionIf unrecognized, this complication may lead to life-threatening internal bleeding. It is important to look for an occult bleeding source with such a presentation, and prompt intervention is essential.     

Ruptured Degenerating Fibroid Causing Preterm Labour and Systemic Inflammatory Response Syndrome

BackgroundFibroids are present in at least 10% of pregnancies and are recognized to cause a variety of complications. A few case reports have described fibroids as an etiological factor in uterine rupture, sometimes with life-threatening hemorrhage.CaseA 28-year-old G1, P0 woman at 20 weeks gestation developed systemic inflammatory response syndrome with acute renal failure and massive ascites secondary to a ruptured degenerated fibroid. This resulted in preterm delivery and neonatal death. At 6 weeks postpartum, she successfully underwent an abdominal myomectomy.ConclusionThis is a rare case of uterine fibroid rupture causing preterm labour and systemic inflammatory response syndrome. This report discusses the diagnosis of uterine rupture related to the fibroid with imaging and subsequent management, which included fertility-preserving surgery.     

Economic Evaluation of Prenatal Carrier Screening for Fragile X Syndrome

This study is a reanalysis of the first scientific paper published by one of the authors, originally coauthored with Dr. Roy H. Petrie. In honor of Dr. Petrie, these data have been reanalyzed to re-evaluate the data using more sophisticated techniques and to expand on the original findings. This reanalysis examines the contribution of maternal weight gain to infant birthweight and retained maternal weight in the immediate postpartum period, and the effect of weight gains below, at, and above the Institute of Medicine (IOM) guidelines on both infant birthweight and retained maternal weight in the postpartum period. The study population included 487 term, uncomplicated, singleton pregnancies. Body mass index (BMI) was calculated for each woman, and categorized as underweight, normal weight, or overweight. Maternal retained weight was calculated as postpartum weight 2 days after delivery minus pregravid weight. Every kilogram of gestational weight gain increased birthweight by 44.9 g for underweight women, 22.9 g for normal weight women, and 11.9 g for overweight women. For every kilogram of retained weight, birthweight was increased by 35.6 g for underweight women, 15.9 g for normal-weight women, and 5.1 g for overweight women. Increasing weight gains from below to equal to IOM guidelines increased birthweight and maternal retained weight by 317 g (11%) (P < 0.01) and 5 kg (P < 0.01), respectively, for underweight women; 141 g (4–4%) (P < 0.02) and 6.2 kg (P < 0.01), respectively, for normal-weight women; and 200 g (6.4%) (NS) and 6.4 kg (P < 0.01), respectively, for overweight women. Increasing weight gains from equal to above the IOM guidelines increased birthweight and maternal retained weight by an additional 299 g (9.4%) (P < 0.02) and 7.3 kg (P < 0.01), respectively, for underweight women; an additional 196 g (5.9%) (P < 0.01) and 5.9 kg (P < 0.01), respectively, for normal weight women; and an additional 9 g (0.3%) (NS) and 8.3 kg (P < 0.01), respectively, for overweight women. These findings suggest that, beyond a certain level of weight gain, there is a point of diminishing returns (increase in birthweight) at the expense of increasing maternal postpartum obesity for the woman who has gained excessively.     

Spontaneous Cervicovaginal Fistula in Obstructed Hemivagina and Ipsilateral Renal Anomaly Syndrome: A Case Report

BackgroundObstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare diagnosis; patients classically present with dysmenorrhea and increasing pelvic pain. Unusual manifestations of OHVIRA syndrome might occur as a result of patient anatomy and the rupture or relief of the obstructed hemivagina.CaseWe present a 15-year-old patient with OHVIRA syndrome who developed a spontaneous cervicovaginal fistula and subsequently underwent hemihysterectomy.     

Persistently elevated nuchal translucency and the fetal heart

Objective: To describe the outcome of fifteen cases with an elevated nuchal translucency (NT) which persisted into the second trimester as nuchal edema (NE) >6?mm whom underwent fetal echocardiography.

Materials and methods: Cases were identified following retrospective review of cardiac and genetic findings in fetuses with NE.

Results: Minor congenital heart disease was identified in 3/15 by the second trimester. Agenesis of the ductus venosus was evident in four. Pulmonary valve stenosis was diagnosed in one fetus at the 20-week scan and hypertrophic cardiomyopathy in one. However, hypertrophic cardiomyopathy or pulmonary valve stenosis was present after birth in all surviving cases by 3 months of age. On the basis of intention to treat, 11/12 survived to delivery and 9/12 survived to 28 days. There were 6 deaths before 14 months of age as a result of severe hypertrophic cardiomyopathy. Noonan syndrome was confirmed with genetic testing in 11/15 cases.

Conclusions: All fetuses with NT and NE had evidence of congenital heart disease at birth, and therefore, late gestation and postnatal review is recommended even when second trimester echocardiogram is considered normal. There is a high prevalence of Noonan syndrome and targeted genetic analysis should be considered. The outcome in these cases is poor.     

The Association between Immediate Postpartum Etonogestrel Implants and Positive Postpartum Depression Screens in Adolescents and Young Adults

ObjectiveWe aimed to compare rates of positive postpartum depression screens at 6 weeks postpartum among adolescents and young adults (AYA) initiating immediate postpartum contraceptive implants and those initiating other methods.DesignThrough a retrospective observational design, we collected data on demographics, reproductive history, prenatal and postnatal depression, and postpartum contraception.SettingPatients participating in an AYA prenatal-postnatal program were eligible for inclusion.ParticipantsA total of 497 patients were enrolled between January 2013 and December 2016. The median age was 19 years (range 13-22 years); 86% were primiparous, 50% were Latina, 24% were black, and 16% were white; 34% initiated immediate postpartum implants (n = 169).InterventionThose initiating a contraceptive implant within the first 14 days postpartum were included in the intervention group.Main Outcome MeasureWe compared rates of positive Edinburgh Postpartum Depression Scales (EDPS) (scores ≥10) in AYA initiating immediate postpartum implants and those initiating other contraceptive methods.ResultsThe AYA initiating immediate postpartum implants were similar to the rest of the cohort in baseline characteristics, aside from an increased rate of preterm births among the intervention group (19.4% vs 12.1%; P = .03). Prenatally, 14% had an elevated Center for Epidemiologic Studies Depression Scale (CES-D) scores (11.5% immediate postpartum implants vs 15.4% comparison, P = .25). At 6 weeks postpartum, 7.6% had a positive postpartum depression screen; this rate was significantly lower for those initiating immediate postpartum implants compared to those choosing other methods (4.1% vs 9.5%, P = .04).ConclusionsProviders should continue to encourage AYA to choose whichever highly effective contraceptive method they prefer for postpartum use.     

Possible Gynecologic Manifestations of Keishi-Bukuryo-Gan Syndrome: A Case Report

BackgroundKeishi-Bukuryo-Gan (KBG) syndrome is a rare genetic disorder that can present with dysmorphic facial features as well as skeletal, neurological, and developmental abnormalities. Little is reported or understood about the gynecologic associations with KBG syndrome.CaseMonozygotic twin 14-year-old sisters, both with KBG syndrome, presented independently with abdominal pain, for which they both underwent laparoscopic appendectomies. Intraoperatively, there was no evidence of appendiceal pathology. Both patients were noted to have abnormally appearing elongated ovaries, and 1 was also diagnosed with endometriosis.Summary and ConclusionThe aim of this paper was to highlight a possible gynecologic association with KBG syndrome. For providers caring for this unique subset of patients, it could lower the threshold to suspect endometriosis and increase the suspicion for ovarian dysmorphism.     

Atypical Presentation of Swyer Syndrome

BackgroundSwyer syndrome is a rare type of disorder of sex development and typically presents with delayed puberty and primary amenorrhea. We describe an unusual presentation of this condition.CaseA 17-year-old female patient with typical thelarche and adrenarche presented with primary amenorrhea. Pelvic ultrasound showed normally developed uterus and bilateral ovoid hypoechoic structures suggestive of gonads. Laboratory investigations revealed highly elevated gonadotrophins with estradiol level within a range typical for a female of reproductive age and chromosome analysis showed a 46,XY karyotype. Histopathological examination of the gonadectomy specimens revealed gonadoblastoma and dysgerminoma with no functional ovarian or testicular tissue.Summary and ConclusionThis report reminds us the possibility of diagnosis of Swyer syndrome in the presence of normal pubertal development and normal sex steroid levels considered to be produced by gonadoblastoma.     

Risk Estimation of Metabolic Syndrome at One and Three Years After a Pregnancy Complicated by Preeclampsia

BackgroundOur goal was to determine the prevalence of metabolic syndrome in women following a pregnancy complicated by preeclampsia and to determine whether this changes between one- and three-years postpartum.MethodsWe recruited women into a longitudinal prospective cohort following a pregnancy with or without preeclampsia. The prevalence of cardiometabolic factors were assessed at one- and three-years postpartum. A total of 217 women completed a visit at one year postpartum (n = 99 preeclampsia, n = 118 control subjects) and 120 completed a visit at three-years (n = 73 preeclampsia, n = 47 control subjects).ResultsThe prevalence of metabolic syndrome at one- and three-years postpartum was significantly greater in women who had preeclampsia (18.18% at one year, 21.92% at three-years) than in control subjects (6.78%, 6.38%) (P < 0.05), but did not change over time.ConclusionGiven the difficulty in following women long-term,either clinically or as part of study, and because cardiometabolic factors do not change significantly between one- and three-years postpartum, strategies for health preservation and disease prevention should be adopted in the first-year postpartum.     

Extensive hepatic infarction in severe preeclampsia as part of the HELLP syndrome (hemolysis,elevated liver enzymes,and low platelets): Evolution of CT findings and successful treatment with plasma exchange therapy

ObjectiveWe describe the serial computed tomography (CT) findings of extensive hepatic infarction and successful plasma exchange therapy in a severe preeclamptic woman with postpartum HELLP syndrome.Case ReportA 38 year-old woman presented with elevated blood pressure of 140–180/90–120 mmHg and 3+ proteinuria at 28 weeks of gestation. Two days after admission, the patient suddenly complained of severe epigastric pain and headache. Her blood pressure rose sharply to 195/120 mmHg. A 980 g female was delivered by emergency cesarean section. Following delivery, the patient's clinical condition and laboratory values deteriorated, with progressive liver insufficiency (peak AST level = 4246 IU/L, ALT = 3685 IU/L, LDH = 6237 IU/L, platelets = 72,000/mm³). Two consecutive plasma exchanges (PEX) were undertaken on the 3^rd and 4^th postpartum day. A contrast-enhanced CT of the abdomen performed 8 days postpartum showed geographically wedge-shaped areas of low attenuation, with a mottled appearance in the right hepatic lobe. Shortly thereafter, the patient recovered and all laboratory parameters gradually normalized 3 weeks after delivery. Follow-up CT-scan of the liver 2 months postpartum showed no evidence of infarction, with complete recovery.ConclusionWe recommend that severely ill patients with HELLP syndrome having epigastric pain should undergo CT imaging of the liver. A trial of postpartum PEX therapy should be considered for treatment of the HELLP syndrome complicated with hepatic infarction, which is recalcitrant to conventional medical management, and fails to abate within 72–96 hours of delivery.