Cervical Entrapment of a Polythene Vaginal Ring Pessary — a Clinical Curiosity

An extremely rare complication of cervical entrapment of a polythene ring pessary within an epithelial 'tunnel' of the cervix is reported. The pessary was removed by dividing a segment of it with bone cutting forceps.     

Uterine Rupture After Induction of Labour for Intrauterine Death Using the Prostaglandin E2 Analogue Sulprostone

A 30-year old pregnant woman who had had an earlier stillbirth and 2 children, the oldest of whom was delivered by Cesarean section, presented at the National University Hospital in Singapore at 32 weeks because she had not felt fetal movements for 3 days. Doptone did not detect a fetal heart beat and ultrasound confirmed intrauterine death. She did not have any soreness at the previous lower segment Cesarean scar. After she opted to have labor induced, health workers injected 0.5 mg of the prostaglandin E2 analogue, sulprostone, into a muscle every 6 hours. Painful uterine contractions did not start until after the 2nd injection of sulprostone. 20 hours after the 1st injection, her pulse increased to 100/minute, blood pressure fell from 120/70 to 80/50, and she began to perspire. She noted tenderness at the lower segment scar. Abdominal examination did not reveal any free fluid. There was no blood in the urine. 20 minutes after her blood pressure increased to 100/70, the woman had steady abdominal pain and vaginal bleeding. Her abdomen swelled and rebound tenderness occurred. Physicians diagnosed uterine rupture and performed a laparotomy promptly. They found 800 ml of free blood in the peritoneal cavity and a complete rupture all along the Cesarean scar. The removed the dead fetus and repaired the scar. They also applied Filshie clips on her Fallopian tubes since she wanted to be sterilized. She was discharged 7 days after laparotomy and recovered uneventfully. This case report confirms that vaginal delivery at term after lower segment Cesarean section is no guarantee against scar rupture in subsequent pregnancies, particularly when health workers use prostaglandins. Nevertheless, prostaglandins are still a reasonably safe and predictable method of terminating pregnancy even in cases of previous Cesarean section. It is important that health workers supervise closely women who have had a Cesarean section and are being administered a prostaglandin to terminate a pregnancy because of the possibility of uterine rupture.     

The Feasibility of Early Second Trimester Pregnancy (12 to 14 weeks) Termination with Single Intra-Amniotic Injection of 15-Methyl PGF2α

Summary: Prostaglandin analogues have proven to be safe and effective for second trimester pregnancy terminations when given by various routes. Of these, the intra-amniotic (IA) route has proven to be safer, especially in women with medical disorders, as it causes the least occurrence of systemic side-effects. Previously, blind transabdominal IA instillation of the analogue 15-methyl PGF₂a was routinely possible only after 16 weeks' gestation. With the advent of ultrasound-guided techniques, it has now become possible to use the IA route for very early second trimester pregnancies. This study examines the use of single 1.5 mg 15-methyl PGF₂a IA injection for termination of 12–14 weeks pregnancies. Single injection resulted in successful abortion in 76.5% of women and, in the unsuccessful cases, additional prostaglandin injection resulted in successful abortion in all women within 48 hours without problems. It is therefore feasible to use ultrasound-guided IA prostaglandin injection for successful termination of early second trimester pregnancies.     

Inflammatory pseudotumors of the central nervous system

Inflammatory pseudotumor is a disease with unsettled pathogenesis. The brain is a rare site of occurrence. The aim of this study is to investigate ALK-1 protein expression and IgG4-positive plasma cells detection in 4 intracranial inflammatory pseudotumors. Three dural-based and 1 intraventricular inflammatory pseudotumors were retrieved from the hospitals' archive. The data on clinical presentation, radiological findings, procedure undertaken, and patients' progress were collected. Sections from the excised lesions were examined under hematoxylin and eosin, histochemical, and immunohistochemical staining including ALK-1 and IgG4. All 4 cases displayed typical histological features of inflammatory pseudotumor with dense lymphoplasmacytic infiltrate admixed with small number of benign-looking spindle cells in a collagenous stroma. Three cases exhibited high density of IgG4-positive plasma cells per high-power field. ALK-1 was negative. ALK expression was not found in any of our cases. On the contrary, the detection of significant number of IgG4-positive plasma cells in 3 inflammatory pseudotumors suggests that a considerable proportion of intracranial inflammatory pseudotumor may belong to the IgG4-related subgroup. Hence, a trial of corticosteroid after histological confirmation may be valid to avoid unnecessary risk-taking neurosurgical procedures or in cases with incomplete tumor removal.     

Blood Loss in Termination of Early Pregnancy with Mifepristone and Gemeprost

EDITORIAL COMMENT: We accepted this paper for publication because it provides further evidence that the combination of an antiprogestogen and prostaglandin provides a medical termination of pregnancy with the median blood loss being approximately 90 mL and the median number days of bleeding 4. The amount of bleeding is comparable to a heavy period of normal duration albeit there being the risk that bleeding can be excessive. The antiprogestogen mifepristone is not available in Australia
Summary: The combination of an antiprogestogen with prostaglandin has been shown to be an effective alternative to surgical procedures for pregnancy termination in the first 49 days of amenorrhoea and has been available in France since late 1988. Mifepristone when used alone caused poor efficacy with unacceptable vaginal bleeding. The addition of a prostaglandin analogue (sulprostone, gemeprost) produced acceptable efficacy with less bleeding. The present study provides a quantitative assessment of blood loss in a sample of 20 women undergoing medical termination of early pregnancy (amenorrhoea ± 49 days). Vaginal bleeding occurred between days 3 and 15 of commencing therapy. The median number of days of bleeding was 4 with a median blood loss of 91.5 mL. The mean blood loss was 136.8 mL (± SD 159.2) but this did not adversely affect the hemoglobin level in the volunteers. Most patients describe the experience as that similar to a heavy period and viewed the procedure positively especially since they are spared the anaesthetic risks and hospitalization attendant with surgical abortion. Caution is still however advised as there may be the occasional subject with excessive haemorrhage (as in this study where one woman bled a total of 761.4 mL) and close supervision by a physician is essential.