[A rare differential diagnosis of a pregnancy gestosis]

HISTORY AND ADMISSION FINDINGS

After an unremarkable course of her pregnancy a 26-year-old woman was admitted in the 32nd week because of her poor general condition with nausea, vomiting and headache. Her blood pressure was 220/140 mmHg and the pulse irregular with a rate of about 90/min.

INVESTIGATIONS

The urine was markedly positive for glucose and protein, the cardiotachogram was unremarkable.

DIAGNOSIS, TREATMENT AND COURSE

Antihypertensive treatment was started because pre-eclampsia was suspected. At first the patient's condition improved, but a few hours after admission an emergency section had to be performed for maternal and fetal indications, but the eutrophic male child was dead. Postoperatively the electrocardiogram and increased creatine kinase activity were suspicious of an acute myocardial infarction. Chest radiogram and echocardiography showed signs of marked ventricular dysfunction. Coronary angiography excluded coronary artery disease. The concentrations of catecholamine and its metabolites in 24-hour urine were greatly elevated above normal. Ultrasound and computed tomography demonstrated a tumour in the region of the left adrenal suggesting phaeochromocytoma, a diagnosis that was confirmed when the tumour was resected.

CONCLUSIONS

Phaeochromocytoma is a rare cause of toxaemia of pregnancy and presents a high maternal and fetal risk. Its prognosis for both mother and child can be improved only if it is diagnosed and treated prenatally.

Uterine artery embolization--a successful treatment to control bleeding cervical pregnancy with a simultaneous intrauterine gestation

A case of a woman suffering from a bleeding heterotopic cervical pregnancy is described. The concurrent cervical pregnancy and intrauterine gestation were diagnosed by ultrasound and bleeding was initially controlled with selective fluoroscopic uterine artery embolization. A selective fetal reduction was done with ultrasound-guided intracardiac potassium chloride. Uterine artery embolization has been used successfully to control haemorrhage in cervical pregnancies when the main goal was to allow preservation of the uterus, thus maintaining potential fertility. This is the first report of arterial embolization used to control bleeding for maintaining a concurrent intrauterine heterotopic pregnancy in an in-vitro fertilization patient. Unfortunately, subsequent conservative measures led to undesired outcome. This procedure initially controlled the bleeding without disrupting the intrauterine fetal cardiac activity.

[A rare etiology of abdominal calcifications: lithopedion]

We report a case of a rare and particular cause of abdominal calcifications represented by the lithopedion. We describe different radiologic appearances observed by: abdominal plain film, echography and CT. It appeared to us that abdominal plain film alone is sufficient for diagnosis and undertaking surgery. Echography and CT are helpful, especially for complementary evaluation.

Primary term ovarian pregnancy superimposed by intrauterine pregnancy: a case report

A case of primary ovarian pregnancy proceeding upto term superimposed by another intrauterine pregnancy is presented. Compound extrauterine and intrauterine pregnancy is a rare obstetric phenomenon and still rarer is a primary ovarian pregnancy proceeding upto the term. The condition was diagnosed at laparotomy during the second trimester of current pregnancy. Diagnostic laparotomy was done because the ovarian pregnancy was mimicking an ovarian tumur. The ovarian pregnancy was successfully managed by surgery. Normal vaginal delivery of a term intrauterine pregnancy occurred in due time. The difficulty of diagnosing the heterotopic pregnancy is discussed and the clinico-pathological features of primary term ovarian pregnancy is emphasized, as it is a very rare condition.

[A case of abdominal pregnancy--a case report]

Rare anatomical variety, the ectopic abdominal gestation involve a high maternal and foetal risk. On report an abdominal gestation in the 2nd quarter of evolution at a 42 yrs. age of a female with multiple uterine leiomyomas, the diagnosis being establish by ultrasonography. The attitude in the same cases is decided by the foetal viability: if the foetus is in a life, the pregnant women is hospitalised and followed each day; if the foetus is dead, there are indication of surgery, the major problem being represented by the total or partial removed of the placenta.

Excitement in an elephant after intravenous administration of atropine

A 28-year-old Asian elephant (Elephas maximus) was anesthetized for cesarean section to remove a dead calf. The elephant was sedated with azaperone, and atropine was administered IV 90 minutes later in preparation for induction of anesthesia with etorphine HCl. Within 1 minute of injection of atropine, the elephant began swaying, kicking, and moving in an agitated manner around the stall. There is considerable variation among species in the toxicity of atropine, although development of toxicosis usually is associated with overdosage.

Fetal decapitation: the application and safety of the stout embryotomy scissors

Transverse lie with impacted shoulder and hand prolapse of the dead fetus was treated in 21 cases by decapitation of the fetus, performed with stout blunt-ended embryotomy scissors. Surgical complications were minimal and the procedure was simple, effective and safe.

Destructive operations still have a place in developing countries

OBJECTIVES

To determine the place of destructive operations in developing countries in patients arriving late in labor with a dead fetus and advanced infection, and to compare them with LSCS for patients with similar indications.

METHODS

A total of 56 cases of destructive operations were carried out on patients with obstructed labor and intrauterine fetal death (IUFD) from the labor wards of Smt. S.K. Hospital from January 1985 to December 1991. These were compared with 27 cases of LSCS done for similar indications during the years 1989 to 1990.

RESULTS

Patients treated with destructive operations had no maternal deaths, had very few complications and required a short hospital stay. Patients treated by LSCS, however, had one maternal death and complications such as post-partum hemorrhage, incidence of blood transfusion, post-operative shock, post-operative pyrexia and duration of hospital stay were more frequent.

CONCLUSIONS

It is felt that in some properly selected cases presenting late with obstructed labor, IUFD and intrauterine sepsis, destructive operations should be performed as first choice. Thus, destructive operations still have a limited place in developing countries and are safer than LSCS for these patients.

Midtrimester induction of abortion: comparison of extraovular prostaglandin E2 and intra-amniotic prostaglandin F2 alpha

The efficacy of extraovular prostaglandin E2 and intra-amniotic prostaglandin F2 alpha for pregnancy termination in midtrimester was compared. A retrospective review of pregnancy termination in midtrimester using intra-amniotic instillation of 40 mg of prostaglandin F2 alpha (n = 133) or extraovular instillation of prostaglandin E2 at a rate of 500 micrograms/hour (n = 81) was performed. Both groups had a similar mean induction-to-abortion interval (19.5 +/- 19.9 and 20.9 +/- 18.2 hours for extraovular PGE2 and intra-amniotic PGF2 alpha, respectively) and a similar success rate of abortion within the first 24 hours of initial treatment (84.0% for extraovular PGE2 and 76.7% for intra-amniotic PGF2 alpha). The two groups had a similar and low (9.8%) incidence of complications. It is concluded that either of the methods used in the study (i.e. extraovular PGE2 or intra-amniotic PGF2 alpha) can be used safely and effectively for pregnancy termination in midtrimester.

Evaluation of the role of craniotomy in developing countries

A review of 32 cases of craniotomy performed at the Jinnah Postgraduate Medical Centre Karachi, over a period of 6 years from January, 1984 to December, 1989 is presented. Total number of deliveries during this period were 37,682. Frequency of craniotomy was 0.08% i.e., 1 in 1177 deliveries. Of these 32 craniotomies, 28 were done on non-deformed dead fetus, 16 because of obstructed labour, 7 in cases of after coming head of breech and 5 in failure to progress in second stage of labour. Four cases were of live hydrocephalic fetus in whom cephalocentesis was done followed by craniotomy due to failure to progress in labour. Maternal morbidity was 12.5% with no maternal death. We conclude that it is safe and quicker than caesarean section in selected cases. Though unpleasant to perform, is of great relief to the patient and her family.

Caesarean sections in cattle attended by a practice in Cheshire

The results of 77 caesarean sections in cattle carried out in a seven-person practice over a period of 16 months are described and evaluated. The standardisation of the surgical technique, the speed of decision making in dealing with dystocia, and the education of the farmers contributed to the 84 per cent calf survival rate, and post surgical complications were few. There was only one fatality in a dam.

[Intrauterine death of one fetus in twin pregnancy]

A case of twin pregnancy complicated by intrauterine death of a foetus is reported. The most recent literature data on incidence, aetiology, diagnostic and monitoring difficulties (improved over the past few years thanks to echography) are discussed. Finally, prevention problems and the choice of therapy are examined, it being stressed that it is by now a widespread habit to close these pregnancies with Caesarean section as soon as the maturity of the surviving twin so permits.

Effects of dystocia on postpartum adrenocortical function in dairy cows

Postpartum adrenocortical responses to adrenocorticotropic hormone in cows after normal (n = 10) and difficult (n = 52) parturition were investigated. The post-partum adrenocortical function of cows was affected by type of parturition (spontaneous parturition, forced extraction of fetus, caesarean section calving with or without attempted forced extraction, and total fetotomy) and day after calving (d 1, 4, and 8; d 0 = day of parturition). Cows after normal calving did not show enhanced or depressed adrenocortical function postpartum. Adrenocortical function was enhanced, compared with cows calving normally, for cows with dystocia that had a caesarean section after forced extraction was attempted and in cows in which calves were already dead and total fetotomy was performed. Cows with dystocia assisted with forced extraction by one to two people and cows that had caesarean sections without forced extraction did not show higher plasma glucocorticoid concentrations before or after adrenocorticotropic hormone administration than did cows with normal calving. Results indicate that dystocia requiring caesarean section following unsuccessful extraction or total fetotomy enhanced postpartum adrenocortical function in cows.

Fetal hydrops and death from sacrococcygeal teratoma: rationale for fetal surgery

Most sacrococcygeal teratomas diagnosed before birth can be managed by planned delivery and postnatal surgery. However, large tumors early in gestation may result in placentomegaly, hydrops, and fetal death and a preeclampsia-like syndrome in the mother. This chain of events may result from high output cardiac failure in the fetus caused by arteriovenous shunting through the tumor. We recently encountered this situation in a fetus at 21 weeks' gestation and performed fetal surgery in an attempt to reverse the process. Excision of the teratoma resulted in reversal of hydrops, diminution of descending aortic flow on Doppler echocardiography, and decrease in placental thickness. Despite these changes, uterine irritability after hysterotomy resulted in labor and delivery of a nonviable premature infant. This case demonstrates that when fetal sacrococcygeal teratoma becomes very large early in gestation, high output cardiac failure can endanger both fetus and mother. In the future, use of Doppler echocardiography may allow appropriate selection of high-risk fetuses. Intervention to prevent arteriovenous shunting through the tumor may offer these fetuses an improved chance for survival.

[Abdominal pregnancy. An unusual case]

A general review is made about concept, incidence and clinical features of abdominal pregnancy. The early and accurate diagnosis of an abdominal pregnancy is very important in order to avoid catastrophic hemorrhage from placental separation. A case is reported of a young woman hospitalized at Morelia's General Hospital, SSA, with an abdominal pregnancy. The fetus died about 26th week and underwent mummification. Some time later the fetus spontaneously divided and the lower segment extruded through the intestines. The remain upper thoracic and cephalic segment was removed at laparotomy closing an intestine stoma; 60% of the placenta was also removed. The postoperative course was uneventful.

The microsurgical dissection of a stillborn fetal clubfoot

A microsurgical dissection was performed on a clubfoot of a seven-month-old stillborn fetus with camptomelic dysplasia. The most important anatomic alteration was marked rotation of the calcaneus beneath the talus. The calcaneus was rotated around a vertical axis. Its anterior aspect was rotated medially, while its posterior aspect was rotated laterally. A series of photographs obtained during the dissection shows the degree of realignment achieved by each stage of the progressive or stepwise surgical dissection. Dissection simulating a posteromedial release and plantar release failed to realign the hindfoot. A complete subtalar release was necessary to reposition the bones of the hindfoot completely. In this specimen, metatarsal capsulotomies were required to realign the forefoot, and the osteotomies of the tibia and tibula were required to straighten the angular deformities characteristic of camptomelic dysplasia, as well as the significant external torsion of these bones.

An abdominal mummified fetus in a Macaca assamensis

A case of an ectopic mummified fetus in a Macaca assamensis is described. The condition was detected on routine clinical examination of a newly acquired monkey, and the mummified fetus was surgically removed.