Administration of the etonogestrel contraceptive implant on the day of mifepristone for medical abortion: a pilot study

OBJECTIVE

We sought to determine satisfaction and continuation rates of the contraceptive implant when placed on the initial visit for first-trimester medical abortion.

STUDY DESIGN

In this pilot study, we placed the implant within 15 min of mifepristone administration. We assessed satisfaction with implant placement timing, 1-year implant continuation and abortion completion.

RESULTS

We enrolled 20 participants. Sixteen (80%) returned for follow-up, and all had complete abortion. At 1 year, of 16 participants contacted, 14 (87.5%) were satisfied with implant insertion timing, and 14 (87.5%) continued the implant.

CONCLUSIONS

Initiation of the contraceptive implant on the initial visit for medical abortion resulted in high satisfaction and continuation rates.

IMPLICATIONS

This pilot study provides important groundwork for future larger studies to assess initiation of the contraceptive implant on the day of mifepristone for medical abortion.

Placenta percreta and uterine rupture at 16 weeks

Placenta percreta is a complication of pregnancy with significant morbidity and mortality rates. Spontaneous uterine rupture in early pregnancy due to placenta percreta is rare. We report a case of this life-threatening complication occurring at the sixteenth week of gestation. The patient presented with signs of shock, acute abdomen, and evidence of hemoperitoneum. The pregnancy was viable with a normal ultrasound appearance that created some confusion and there was a dilemma in the diagnosis of this case. Various obstetric and surgical causes were taken into consideration. The patient was taken to the operating room immediately for exploratory laparotomy. She was found to have fundal uterine rupture, which was managed by uterine repair. This patient had prior cesarean section and dilatation and curettage; factors well known to predispose for placenta percreta. Here, we emphasize the importance of a fast decision and surgical intervention to save a patient's life in cases of uterine rupture.

Allopurinol Use during Pregnancy - Outcome of 31 Prospectively Ascertained Cases and a Phenotype Possibly Indicative for Teratogenicity

Allopurinol is a purine analogue that inhibits xanthine oxidase. It is mainly used for the treatment of hyperuricemia in patients with gout or tumor lysis syndrome. Experience with allopurinol in pregnancy is scarce. In 2011, Kozenko et al. reported on a child with multiple malformations after maternal treatment with allopurinol throughout pregnancy. Possible teratogenicity of allopurinol was proposed due to the similarity of the pattern of malformations in children with mycophenolate embryopathy. A possible common mechanism of both drugs, i.e. disruption of purine synthesis, was discussed. We report on the outcome of 31 prospectively ascertained pregnancies with allopurinol exposure at least during first trimester. Pregnancy outcomes were 2 spontaneous abortions, 2 elective terminations of pregnancy and 27 live born children. The overall rate of major malformations (3.7%) and of spontaneous abortions (cumulative incidence 11%, 95%-CI 3–40) were both within the normal range. However, there was one child with severe malformations including microphthalmia, cleft lip and palate, renal hypoplasia, low-set ears, hearing deficit, bilateral cryptorchidism, and micropenis. The striking similarity of the anomalies in this child and the case described by Kozenko et al. might be considered as a signal for teratogenicity. Thus, we would recommend caution with allopurinol treatment in the first trimester, until further data are available.

Pregnancy after endometrial ablation. A report of three cases

BACKGROUND

Pregnancies after endometrial ablation (EA) are rare and are associated with high morbidity, especially in the second and third trimesters.

CASE

We report 3 cases of pregnancy after EA in which severe complications occurred during the first trimester. The first case concerns an unexpected pregnancy after EA in a 50-year-old woman. Hysterectomy via laparotomy was needed because of heavy bleeding and severe anemia. Pathology showed a complete hydatidiform mole without invasion. Ultrasound-guided in situ methotrexate injection could be a nonsurgical alternative to terminate an intrauterine pregnancy after EA when the pregnancy is located within uterine synechiae, as shown by the second case. The third case presented as an accreta placentation mimicking hyperplastic myometrial invasion in a 46-year-old patient.

CONCLUSION

Because of the high morbidity of these pregnancies that could still occur after EA, patients need contraception after EA, and concomitant hysteroscopic sterilization should be proposed at the same time.

Intramural ectopic pregnancy: a case and review of the literature

An intramural ectopic is a rare type of ectopic pregnancy in which the gestational sac is implanted within the myometrium, separate from the endometrial cavity and Fallopian tubes. There are only 53 cases in the published literature. We report a case of intramural ectopic pregnancy treated surgically and review the published data on this rare type of ectopic pregnancy, with respect to aetiology, diagnosis and management.

[Cancer and pregnancy]

To diagnose cancer during pregnancy is a terrible event for the patient and her family and a complex situation for physicians. The management of this clinical situation should be as standardized as possible, most similar to management that would be offered without pregnancy. Except in rare cases, termination of pregnancy is not justified by the cancer itself, because it does not improve the prognosis. Hormone therapy, targeted therapy, chemotherapy in the first trimester, and radiotherapy are most of the time contra-indicated. During the 2nd and 3rd trimesters, management will follow the usual recommendations with surgery and chemotherapy. The delivery term depends on the date of discovery of cancer but is beyond 35 weeks of gestation in the majority of cases. It is at best scheduled between the oncologist and obstetrician to minimize fetal or obstetrical risks. A network exists to help physicians and patients: www.cancer-et-grossesse.fr.

Fertility after tubal ectopic pregnancy: results of a population-based study

OBJECTIVE

To assess the reproductive outcome after an ectopic pregnancy (EP) based on the type of treatment used, and to identify predictive factors of spontaneous fertility.

DESIGN

Observational population based-study.

SETTING

Regional sistry.

PATIENT(S)

One thousand sixty-four women registered from 1992 to 2008.

INTERVENTION(S)

Laparoscopic (radical or conservative), or medical treatment.

MAIN OUTCOME MEASURE(S)

Epidemiologic characteristics, clinical presentation, treatments performed, reproductive outcome, recurrence.

RESULT(S)

The 24-month cumulative rate of intrauterine pregnancy (IUP) was 67% after salpingectomy, 76% after salpingostomy, and 76% after medical treatment. IUP rate was lower after radical treatment compared with conservative treatments in univariable analysis. In multivariate analysis, IUP rate was significantly lower for patients >35 years old or with history of infertility or tubal disease. For them, IUP rate was significantly higher after conservative treatment compared with salpingectomy. The 2-year cumulative rate of recurrences was 18.5% after salpingostomy or salpingectomy and 25.5% after medical treatment. History of infertility or of previous live birth would be protective, in contrast to history of voluntary termination of pregnancy.

CONCLUSION(S)

Conservative strategy seems to be preferred, whenever possible, to preserve patients' fertility without increasing the risk of recurrence. The choice between conservative treatments does not rely on subsequent fertility, but more likely on their own indications and therapeutic effectiveness. Risk factors of recurrence could be considered for secondary prevention.

Complicating preeclampsia as a predictor of poor survival of the fetus in complete hydatidiform mole coexistent with twin fetus

OBJECTIVE

To examine whether preeclampsia is a predictive factor for fetal prognosis in complete hydatidiform mole coexistent with twin fetus (CHMCF).

STUDY DESIGN

We performed a retrospective chart review for 17 cases of definitive CHMCF managed in our hospital between 1991 and 2011.

RESULTS

Fifteen patients chose expectant management and the remaining 2 selected termination of the pregnancy. During expectant management 6 patients displayed hypertension with proteinuria, representing preeclampsia, by the 2nd trimester (11-24 weeks) and the other 9 did not (nonpreeclamptic). No babies from preeclamptic mothers survived, with 5 intrauterine fetal deaths at 16-29 weeks and 1 neonatal death at 22 weeks. By contrast, 5 babies from 9 nonpreeclamptic mothers (1 preterm delivery at 29 weeks and 4 term deliveries) survived, while 4 pregnancies were lost by spontaneous abortion at 11-19 weeks. Low-risk gestational trophoblastic neoplasia (GTN) eventually occurred in both preeclamptic (4 of 6) and nonpreeclamptic (4 of 11) cases. Complicating preeclampsia correlated significantly with fetal demise and an increasing trend in serum hCG level but not with postmolar GTN.

CONCLUSION

Complicating preeclampsia predicts poor survival of the fetus, but not subsequent GTN, in CHMCF.

Prenatal diagnosis of diastematomyelia: a case report and review of the literature

Diastematomyelia is a rare congenital disorder in which the spinal cord is divided longitudinally for part of its length. It can be accurately identified in the prenatal period by detailed sonographic examination of the spine. We report a case of diastematomyelia localized to spinal levels T6-T9 diagnosed prenatally at 31 weeks' gestation and review the existing literature on the diagnosis and management of this condition during pregnancy.

Efficacy of local aspiration in the conservative treatment of live interstitial pregnancy coexisting with live intrauterine pregnancy after in vitro fertilization and embryo transfer

BACKGROUND

Heterotopic pregnancy (HP) is defined as a pregnancy in which one or more embryos is viably implanted in the uterus while the other is implanted elsewhere as an ectopic pregnancy. The occurrence of HP rises dramatically with the increased use of assisted reproductive technology. HP of interstitial pregnancy is one special situation which needs more concern. Here we evaluate the efficacy of local aspiration and instillation of hyperosmolar glucose in the treatment of live interstitial pregnancy complicated with live intrauterine pregnancy after in vitro fertilization and embryo transfer.

METHODS

Five female patients were diagnosed with live interstitial pregnancies complicated with intrauterine pregnancies. They were treated with transvaginal ultrasound-guided aspiration of interstitial pregnancy and instillation of hyperosmolar glucose at the Center for Reproductive Medicine of Peking University Third Hospital from January 1st, 2008 to May 30th, 2011.

RESULTS

Gemmule embryos in all 5 cases were aspirated successfully and there was no abdominal hemorrhage, threatened abortion or infection in any of the cases. The sac of interstitial pregnancy continued to progress after aspiration and stopped growing between 11 to 20 weeks. By the 30th week of pregnancy, 80% of the interstitial masses had disappeared. Four cases have delivered and one is still in on-going pregnancy. All of the four cases underwent cesarean section and there were nothing special detected in the corner of the uterus.

CONCLUSION

Local aspiration and instillation of hyperosmolar glucose may be an effective way to treat live interstitial pregnancy when coexisting with a live intrauterine pregnancy.

Autopsy findings in fetuses with cystic hygroma: a literature review and our center's experience

PURPOSE OF INVESTIGATION

To report our experience of autopsied cases of fetal cystic hygroma (CH) and discuss the role of fetal autopsy in genetic counseling.

METHODS

A review of autopsy reports at our institution revealed 18 cases of fetal CH over a 10-year period (from 2000 to 2010). The clinical data, results of cytogenetic analysis and prenatal ultrasound findings were also retrieved and compared to the autopsy findings.

RESULTS

Fetal death was due to intrauterine death in eight cases, therapeutic abortion in eight cases and spontaneous abortion in two cases. Cytogenetic analysis was available in 12 cases, and the results showed an abnormal karyotype in seven cases (5 cases of Turner syndrome and 2 cases of trisomy 21). The mean size of CH was 5.4 cm. Other malformations or findings suggestive of the cause of fetal death were diagnosed in 10/18 cases (55.6%). The most common autopsy findings were hydrops and central nervous system anomalies. The autopsy findings were in agreement with the prenatal ultrasound findings in 13/18 cases (72.2%), while in five cases (27.8%) additional findings were detected during autopsy. The most common placental abnormalities were infarcts and calcifications.

CONCLUSION

In addition to prenatal diagnostic studies, fetal autopsy and pathologic examination of fetal and placental tissues may help to establish the exact cause of death and disclose important information as to the presence of various fetal malformations or placental abnormalities.

[Cardiac angiosarcoma in a pregnant women]

We present a case of cardiac angiosarcoma in a pregnant women. Clinical manifestations of angiosarcoma were unspecific and progressed rapidly as hemopericardium, cardiac tamponade, heart failure, fever, chest pain. Pregnancy was interrupted at 22-nd week. The patient died in 6 months after appearance of first symptoms.

[HELLP syndrome--severe complication during pregnancy]

HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is a severe microcirculatory disturbance during pregnancy, associated with pre-eclampsia, but it may occur also without it. In HELLP maternal morbidity and mortality have increased. Typical complications include coagulation disorder, acute respiratory failure, acute renal failure, infections, central nervous system symptoms, hepatic failure and bleeding, and premature ablation of the placenta. The only effective means to treat the syndrome during pregnancy is termination of pregnancy.

[Sirenomelia apus. Case report]

We report a case of Sirenomelia. The mother began prenatal care in the second trimester. Transabdominal ultrasound was determined anhydramnios, cardiac abnormalities and lumbosacral spine. We obtained a single fetus of 21 weeks' gestation with fused lower extremities from the hip to finish in a stump without the presence of feet. Heart with transposition of the great vessels, among other birth defects. It was classified as symelia, Apodi apus, monopodio sirenoide, siren ectropodia, type VI. It is important to diagnose early, because it is a serious and deadly disorder.

[Partial molar pregnancy. A case report and literature review]

We report the case of a 17 year old patient with partial molar pregnancy and coexistent live fetus of 13 gestational weeks diagnosed by ultrasound, which required the termination of pregnancy for maternal decompensation.

[Primary pulmonary hypertension in pregnancy--a case report]

Primary pulmonary arterial hypertension, so called idiopathic pulmonary arterial hypertension (IPAH), is a rare and progressive disease with poor prognosis. Pregnancy in patients with this condition is hazardous and makes the prognosis significantly worse. According to WHO, IPAH is a contraindication to pregnancy because of high risk of maternal death and WHO advises to discuss termination in the event of pregnancy Below we describe a case of a young woman at 16 weeks pregnancy with severe decompensated primary pulmonary hypertension. The patient was admitted to our department because of increasing dyspnoea and swollen legs occurring from 14th week of pregnancy. In the past the patient had been diagnosed with pulmonary hypertension, which had been defined during differential diagnostics as primary pulmonary hypertension. Echocardiographic examination over the last 4 years revealed stable mean pulmonary artery pressure (PAP) of about 50 mmHg. The patient was treated efficiently with sildenafil for the last 2 years, but the therapy was discontinued after finding pregnancy. On admission it was established that pregnancy should be terminated. Other reasons of circulatory decompensation, such as pulmonary embolism, cardiac tamponade or pulmonary diseases, were excluded.

[HELLP in the second trimester in a patient with antiphospholipid syndrome]

The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP) is estimated to occur in 0.01-0.2% of pregnancies and is considered a severe form of preeclampsia. It is associated with considerable risk of maternal and foetal mortality. HELLP syndrome associated with antiphospholipid syndrome is known to occur early in the pregnancy. We report a case of severe HELLP syndrome complicated by multiple hepatic infarctions and portal vein thrombosis in the second trimester in a patient with antiphospholipid syndrome.

Virilizing ovarian Krukenberg tumor in a 27-year-old pregnant woman. A case report and literature review

A case is reported of a 27-year-old pregnant woman with ovarian tumors, measuring 12 cm and 11.5 cm in the greatest diameter, discovered during investigation for virilization symptoms. Termination of the pregnancy at the 22nd week of gestation and tumorectomy with both adnexa were performed, with the provisional diagnosis of arrhenoblastoma. Pathological examination of the tumors showed typical Krukenberg neoplasms and subsequent upper GI tract endoscopy revealed a gastric cancer that was excised. The pathological examination revealed a diffuse type gastric adenocarcinoma with signet ring morphology, similar to ovarian tumors. In any case of ovarian tumor with unusual hormonal manifestations, in addition to hormonally active sex cord-stromal neoplasms, metastatic ovarian tumors must be considered as well, especially in cases of bilateral tumors.

Prenatal detection of full monosomy 21 in a fetus with increased nuchal translucency: molecular cytogenetic analysis and review of the literature

Full monosomy 21 is an extremely rare chromosomal disorder. A 38-year-old woman attended a first trimester scan. Ultrasound (U/S) imaging of the fetus at 12 weeks of gestation showed features of increased nuchal translucency measurement (12 mm). Chorionic villi sampling (CVS) was performed after genetic counseling. At 16 weeks of gestation the fetus showed U/S characteristics of severe intrauterine growth restriction, generalized edema and hydrothorax. Cytogenetic examination was performed using quantitative fluorescent polymerase chain reaction analysis, standard Giesma banding and fluorescent in situ hybridization analysis. Non-mosaic full monosomy 21 was detected and the parents opted to terminate the pregnancy. Microsatellite analysis demonstrated maternal origin of the single chromosome. This case represents one of the few cases of prenatally diagnosed full monosomy 21 confirmed only by CVS, in which the parental origin of the single chromosome was determined.

Compromised chorionic villous vascularization in idiopathic second trimester fetal loss

BACKGROUND

For normal fetal growth and development a well-developed chorionic villous vascularization is essential.

AIM

The aim of this study is to investigate whether idiopathic second trimester fetal loss is associated with an underdeveloped chorionic villous vascularization.

METHODS

38 placentas after late miscarriage, classified as idiopathic fetal loss (IFL, n=16) or as fetal loss due to intrauterine infection (IUI, n=22) were collected. After CD34 immunohistochemical staining the villous stromal area, number of villous vessels, vascular area and vascular area density (central, peripheral and total) were measured in randomly selected immature intermediate villi.

RESULTS

The mean gestational age was 19+4 weeks for the IFL group and 20+6 weeks for the IUI group. After controlling for gestational age, we found no differences in fetal weight, placental weight, villous stromal area, number of vessels and central vascular features. The mean peripheral vascular area and peripheral vascular area density were, after adjusting for gestational age, reduced in the IFL group.

CONCLUSION

Idiopathic second trimester fetal loss is associated with a reduced peripheral chorionic villous vascularization. We hypothesize that in these cases, placentation is already disturbed in first trimester of pregnancy, leading to a reduced materno-fetal interface in second trimester, thus to early postplacental fetal hypoxia and fetal death.