Spontaneous rupture of splenic hemangioma in puerperium

Atraumatic splenic rupture is a rare clinical entity and in the absence of trauma, the diagnosis and treatment are often delayed. In this article the authors discuss a case of a 45-year-old woman, gravida 5, para 4, with spontaneous splenic rupture on her second postpartum day. The rupture was related to a splenic hemangioma that is a vascular malformation and the most common neoplasm of the spleen. Despite the fact that hemangiomas are the most common primary neoplasms of the spleen, only few cases of splenic rupture have been described in pregnancy or puerperium. However, spontaneous splenic rupture is a rare event and the rupture should be suspected in woman with unexplained abdominal pain or with clear signs of haemorrhage.

Leiomyosarcoma after hysteroscopic myomectomy: a case report

OBJECTIVES

The aim of this study was to illustrate the importance of hysteroscopy in the evolution of mitotically active leiomyoma to leiomyosarcoma (LMS). Uterine sarcomas are rare tumors. The three microscopic criteria are: 1) the presence of coagulative tumor necrosis, 2) high mitotic index (exceeding 15 x 10 catabolite gene activator (CGA) and 3) occurrence of moderate to severe cytologic atypia. The authors report a case of a 52-year-old nulliparous woman with a LMS detected two months after a hysteroscopic resection of a mitotically active leiomyoma. After the first hysteroscopic resection the diagnosis was atypical leiomyoma with a mitotic index of two per ten high-power field (hpf) in the absence of coagulation necrosis. After two months, a new myoma was detected and another hysteroscopic resection was performed: the microscopic diagnosis was LMS and a total abdominal hysterectomy with bilateral salpingo-oophorectomy (BSO) was performed.

CONCLUSION

The patient must undergo close clinical and instrumental follow-up procedures. Hysteroscopy plays an important role in the evaluation and evolution of both recurrent and de novo disease.

Aggressive angiomyxoma of the vaginal wall at the initial stage: a case report

Aggressive angiomyxoma (AA) is a rare mesenchimal tumor usually located in the pelvic and perineal region. Less than 30 cases of aggressive angiomyxoma with vaginal location have been reported in the literature up to this date. The authors report the case of a 50-year-old female patient diagnosed with vaginal AA whose characteristics at its initial stage were macroscopically indistinguishable from those of a polypoid lesion. Therefore this case suggests that this type of tumor should be considered as part of the differential diagnosis of vaginal polypoid lesions.

Early ovarian pregnancy diagnosed by ultrasound and successfully treated with multidose methotrexate. A case report

A case report of a primary interstitial ovarian pregnancy is presented. A 37-year-old married woman with two children after two Cesarean sections and a spontaneous abortion, with a contraceptive intrauterine device (IUD) inserted three years before, presented at five weeks plus five days amenorrhea with a positive pregnancy test and lower abdominal pain but with no vaginal bleeding. Her previous menstrual cycles had been regular. She was hemodynamically stable. On bimanual examination, the uterus was of normal size, and there was an approximate four-cm tender right adnexal mass. Serum beta-human chorionic gonadotropin (b-hCG) was confirmed positive. Ultrasound revealed a well-positioned IUD in the uterus and a right adnexal mass with normal vascular flow on Doppler, that contained a well-defined gestational sac, well-distinct from the quiescent hemorrhagic corpus luteum. There was no fetal node or cardiac activity or free fluid. The patient received four injections of methotrexate intramuscularly using the multidose regimen that involves the administration of methotrexate calculated according to body weight, alternated with 0.1 mg/kg of leucovorin calcium per os after 30 hours until the values of 3-hCG had decreased by 15%. The patient's post-treatment period was uneventful with a full restoration of ovarian morphology and the complete absorption of the gestational sac. This case is the first where diagnosis was made by endovaginal sonography and treatment was made by multidose methotrexate. Spiegelberg criteria for the diagnosis of ovarian pregnancy are obsolete; new ultrasound and laboratory criteria are needed for a diagnosis as early as possible without the need of surgery.

The optical trocar in gynecological surgery: clinical and technical outcomes

Optical trocars have been introduced as an alternative technique for obtaining access to the peritoneal cavity. The advantage is that each layer of the abdominal wall can be identified avoiding inadvertent injuries due to a lack of vision. From March 2010 to March 2011, 138 women underwent laparoscopy for benign diseases. They were submitted to gynecological laparoscopy for direct optical access. There was no evidence of vascular injuries. This study confirms that the optical trocar is a safe, rapid, and effective method, that offers a real perception of the safety of the entrance into the abdomen.

Intrauterine balloon tamponade as management of postpartum haemorrhage and prevention of haemorrhage related to low-lying placenta

The aim of the present study was to evaluate the effectiveness of Bakri balloon in preventing and treating postpartum haemorrhage (PPH). Intrauterine Bakri balloon was used in a total of 16 patients with two different purposes: prophylactic placement of the balloon after cesarean section (CS) in six patients with low-lying placenta and therapeutic placement in ten patients with persistent bleeding from uterine atony, after spontaneous delivery, and administration of uterotonics. Intrauterine Bakri balloon was a successful approach in controlling and preventing PPH in all 16 patients. The median nadir hematocrit was 26.6% in six patients who underwent CS and 25.6% in ten patients with persistent bleeding after spontaneous delivery. The intrauterine balloon was in place for a duration of 24 hours. The median balloon infusion volume was 345 ml (range 250-455). No complications were reported. Bakri balloon tamponade was a useful measure in treating PPH unresponsive to pharmacological therapy in patients who delivered vaginally. Moreover, it was able to prevent persistent bleeding in patients who underwent CS for central placenta previa.

Subtle ultrasonographic appearance of Down's syndrome: a case report of prenatal diagnosis of isolated simple fetal syndactyly

Syndactyly is an unusual condition in humans where two or more digits are fused together. In our report we present a case of prenatal diagnosis of simple, complete, bilateral syndactyly as the only ultrasonographic anomaly in a fetus with Down's syndrome. The mother, a 30-year-old, gravida 2, was referred to our hospital with an abnormal triple-test at 17 weeks of gestation, with a final biochemical risk for Down's syndrome more than 1:50. In this pregnancy neither the NT test nor early morphological exam showed typical findings of any chromosomal disorder. The patient underwent amniocentesis. We performed an accurate second level scan at 21 weeks while waiting for genetic results, and we suspected simple, complete, bilateral syndactyly between the third and fourth finger of the hands (rapper sign). The result of the invasive test was 47,XY,+21 and the mother opted for termination of pregnancy; the baby showed simple, complete, bilateral syndactyly of the two digits as suspected during sonography. In presenting our case report, we want to stress the importance of the accuracy of observation of fetal hand morphology, attitude, movements and reactivity. When the observation of fetal hands is not satisfactory (e.g., when the fetus does not open the fist), we recommend external stimulation of fetal reactivity through probe movements on the maternal abdomen (dynamic scan). This approach can make the identification of subtle hand anomalies easier and improve the detection rate of both structural and genetic fetal disorders.

Endometrial tuberculosis: a clinical case

Genital tuberculosis is a bacterial infection still frequent in less developed countries where lots of cases are not diagnosed nor treated. In this work we describe a rare case of primary endometrial tuberculosis in a woman of 50 years old. The diagnosis was confirmed by an ultrasonography of the pelvis and an endometrial biopsy followed by a histological examination. The patient after the diagnosis was put under antiturbecular treatment for six months with complete healing.

Expression of matrix metalloproteinase-9 (MMP-9) in human midpregnancy amniotic fluid and risk of preterm labor

OBJECT

This work stands as a pilot study in assessing the reliability of metalloproteinase-9 (MMP-9) as a marker for intraamiotic infection and preterm birth already in early pregnancy.

SUBJECT

100 amniotic fluids taken at the Midwife Obstetrics and Gynaecological Clinic of the University of L'Aquila (Italy).

RESULTS

Our results show that MMP-9 is a sensitive marker of intraamionic infection (an important risk factor for preterm delivery) already in early pregnancy, because only women with a significant elevation were subsequently exposed to preterm birth.

CONCLUSIONS

Early identification of women at risk of preterm birth is of important clinical significance. Indeed exposing women to deep diagnostic and therapeutic protocols could possibly reduce the incidence of preterm birth in the near future and have a positive impact on fetal prognosis related to unknown intraamniotic infection.

Peripartum cardiomyopathy and Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder of unknown etiology characterized by venous malformations or varicose veins, cutaneous capillary malformation and hypertrophy of soft tissues with limb (usually asymmetric lower extremity) involvement. Peripartum cardiomyopathy (PPCM) is characterized by rapid onset heart failure during the final month of pregnancy or within five months of delivery, in the absence of identifiable risk factors or previous heart disease. The aim of this study was to illustrate the correlation between the KTS and the onset of PPCM in women with twin pregnancies. Our case is a 35-year-old woman, gravida II para I, with KTS, twin pregnancy and PPCM. We can assume that, as the heart of a women with KTS usually works with a low preload reserve due to the widespread venous varicosities, if a significant increase in preload occurs, it may lead to the onset of cardiac dilatation and thus PPCM.

Uterine tumors resembling ovarian sex cord tumors. A case report

Uterine tumors resembling ovarian sex cord tumors (UTROSCT) are rare, usually benign, polypoid or nodular neoplasms which generally arise in the fourth to sixth decade of life. We report a case of a 74-year-old woman who presented with vaginal bleeding and remarkable uterine enlargement. Abdominal hysterectomy with bilateral salpingo-oophorectomy was performed and a diagnosis of UTROSCT was made. Immunohistochemistry is mandatory for a correct diagnosis and a panel of at least two markers of sex cord differentiation is recommended. Differential diagnoses include leiomyosarcoma, UTROSCT and ESTSCLE, mixed müllerian tumor and metastatic ovarian sex cord tumor.

p16INK4a and low-grade cervical intraepithelial neoplasia. Diagnostic and therapeutic implications

The objectives of this study were to evaluate the evolution of a LSIL associated with p16INK4a overexpression and on the basis of this association, identify patients who would benefit from immediate treatment rather than a later follow-up. Two hundred and forty-five cervical biopsies were studied: 199 (81.2%) were classified CIN 1, 18 (7.4%) CIN 2/3 while 28 (11.4%) were not pathological. Immunohistochemistry revealed that 22 of the 217 CIN samples (11%) were positive for the p16INK4a antigen. The results of the PCR-ELISA for the research and typing of the HPV in these 22 cases were: 14 (63.6%) HPV 16; three (13.6%) HPV 31; 2 (9%) HPV 33; one (4.6%) HPV 43; one (4.6%) HPV 45; one (4.6%) HPV 18. Colposcopic and histological tests performed at four- and eight-month follow-ups in these patients revealed worsening of the initial lesion. Hence, we conclude that immediate therapy would be of benefit in these patients.

Primitive breast localisation of Buruli ulcer in an endemic zone: a rare case

A case of Buruli ulcer with primitive breast localisation with evident epidemiological and clinical aspects is reported. This localisation is exceptional; the differential diagnosis with breast cancer is essential. If diagnosed early, it can be cured with surgery, broad-spectrum antibiotherapy and thermotherapy.

[Health-related quality of life in patients with chronic kidney disease]

Assessment of quality of life in patients with different degrees of chronic kidney disease is an important issue because of its impact on clinical decisions and financial resource management in the health-care system. The aim of this study was to assess whether a generic instrument like the SF-36 questionnaire is able to discriminate three different populations of patients with different degrees of renal disease (pre-ESRD, ESRD, TxR). Five hundred sixty-three patients from 12 Italian nephrology units completed the SF-36 scales by themselves. The results from these samples were compared with those from the general population. Univariate analysis and multivariate regression were used. The generic SF-36 questionnaire proved to be a powerful instrument to discriminate populations with different degrees of chronic renal failure. The quality of life of patients on dialysis is significantly worse than that of the normal population and other patients with less severe renal function impairment.

Tuberculosis of the cervix and infertility: report of a rare case

Tubercolosis is a frequent bacterial infection in less developed countries. Lung and lymph node localisations are common, while the genital apparatus is less involved. In this work a rare case of cervical tuberculosis followed by some lesions causing infertility in a 20-year-old woman is reported. The diagnosis was confirmed by a histological examination from a biopsy of the cervix. The patient was offered six-month antituberculosis therapy which eliminated the cervical lesions. A few years later she came under our care for infertility due to uterine adhesions diagnosed by hysterosalpingography. Now the patient is being treated for infertility complicated by amenorrhoea.

Conjugated linoleic acid and black currant seed oil in the treatment of canine atopic dermatitis: A preliminary report

Although conjugated linoleic acid (CLA) shows inhibitory effects on histamine release, eicosanoid production and pruritus in laboratory rodents, its use in canine atopic dermatitis (AD) has not been reported. The aims of this study were to assess the efficacy of CLA, black currant seed oil (BSO) or a combination of both, compared to placebo, in dogs with AD and to evaluate any changes in fatty acid metabolism with these treatments. Twenty-four dogs with AD were randomly allocated to four groups, and were treated orally each day for two months with either 1 mL/10 kg CLA (80% purity), 1 mL/10 kg pure BSO, 1 mL/10 kg CLA+1 mL/10 kg BSO, or 1 mL/10 kg sugar syrup (placebo). Serum was obtained on days 0, 30 and 60 for analysis of CLA metabolites, linoleic acid (LA), gamma-linolenic acid (GLA), dihomo-gamma-linolenic acid (DGLA) and arachidonic acid (AA). At the same time point, the owners were asked to assess pruritus and the veterinarians evaluated any skin lesions present. Although the best clinical results occurred with BSO treatment alone, improvement of clinical signs and pruritus was not significant with any of the treatments. Serum levels of GLA and DGLA significantly increased in BSO-treated dogs, but not in the CLA+BSO group. CLA at the dosage used in this study was not efficacious in treating canine AD, whereas BSO may help some dogs with AD, although further studies are necessary before this can be recommended as a treatment.

Symptom management in a patient with end-stage ovarian cancer: case report

Bowel obstruction is a common complication in patients with far advanced abdominal or pelvic cancer. In patients with recurrent or advanced disease, where options for curative treatment have been exhausted, palliation of symptoms with minimal additional morbidity is the aim of therapy. Owing to the difficulties inherent in conducting perspective randomized trials, clinicians face a significant challenge in managing terminally ill obstructed patients. We evaluated the case of a woman with ovarian cancer. Clinically, the objective of the study was to focus attention on the most up-to-date evidence concerning the treatment of malignant bowel obstruction.

Cytokine levels in amniotic fluid: a marker of preterm labor?

The aim of this study was to determine levels of Interleukin 6 (IL-6) in amniotic fluid at the beginning of the second trimester and to establish whether IL-6 can be used as a marker for premature birth as it would appear to be an important prenatal marker of chorionic inflammation. Thirty-three patients, between 16 and 19 weeks of gestation, who were undergoing amniocentesis to establish the presence or not of fetal genetic pathologies were enrolled into the study. Amniotic fluid (3 ml) was taken from each patient and used to perform enzyme-linked immunosorbent assays (ELISAs). The results were analyzed using the Mann-Whitney test and Pearson and Spearman coefficient. The patients were divided into three groups on the basis of the levels of IL-6 found: a) up to 450 pg/ml; b) between 450 and 900 pg/ml; c) over 900 pg/ml; These data were then evaluated alongside the date of parturition and the presence of any maternal or fetal pathologies. The results of our analyses, however, were inconclusive: levels of IL-6 were normal in patients presenting pathologies while obstetric pathologies were absent in patients with high levels of IL-6. In conclusion, this data would indicate that a different method or approach is required for the identification of a marker for premature birth.

Urinary disorders during pregnancy and postpartum: our experience

The changes that take place in the pelvic region during birth can give rise to alterations in the genitourinary system which are at the basis of pathologies such as stress urinary incontinence (SUI). The occurrence of this condition has been correlated to a variety of factors including neonatal birth weight and obesity. We studied 120 women, 60 nulliparae, 40 primiparae and 20 multiparae who were divided into three groups on the basis of urinary problems experienced. The first group consisted of women who had reported urinary incontinence during pregnancy (76%). This was found to be significantly correlated to the number of pregnancies and weight gained; 18% of this group reported IUS during the postpartum period. The second group consisted of women who did not experience any urinary incontinence during the pregnancy or postpartum while the third group consisted of women who, although not experiencing any urinary problems during pregnancy, reported urinary incontinence in the postpartum period. These data, although only part of an initial study, reveal a consistent frequency of urinary incontinence in pregnancy and postpartum, and highlight risk factors.

[Epidemiologic investigation of the pollen allergy to Cupressaceae in a population at risk for atopy]

The so-called emerging allergens have gained particular interest as causes of atopic diseases, and among these the cypress pollen. In fact, several allergens derived from the Cupressaceae family have appeared for the first time in new environments, thus causing unexpected phenomena. From May 2002 to May 2003 we have examined 560 patients who sought medical attention at the Center for allergic diseases in children. The patients came from various towns and villages from Southern Sardinia and all had undergone prick tests for inhaled allergens, irrespective of their complaints. The presenting symptoms were either respiratory (wheezing cough, rhinitis, asthma), cutaneous (eczema, nettle rash, angioedema) or ocular (conjunctivitis). All patients had a prick test for pollens (cypress, olive, wall pellitory, rag weed, composite, mix gross pollen), acari (Dermatophagoides farinae, Dermatophagoides pteronyssimus), dog and cat hair, and fungi (alternaria alternata, aspergillus fumigatus). Thirteen percent of patients (73/547) resulted allergic to cypress pollen, and three of them had a mono-allergy (4,1%). Among these, one suffered bronchospasm, rhinitis and asthma more severe in January-February associated with recurring small eczematous lesions. Another one suffered bronchial asthma during winter months and the last one complained of rhinitis and nasal itching also during winter months.