Uterine incarceration: a rare diagnosis in non-pregnant women

Uterine incarceration (UI) is a rare complication in non-pregnant women. A woman in her 50s presented to the emergency department with acute urinary retention and paresis of the right inferior limb. A neurological exam suggested a decrease in the right lower limb strength. On gynaecological exam, the cervix was displaced anteriorly and the cul de sac was obliterated with a pelvic mass. CA 19.9 and CA 125 levels were increased. The MRI of the pelvis confirmed an elongated and anteriorly displaced cervix compressing the urethra and the vesical neck due to a uterine mass. A diagnosis of UI was made and an abdominal hysterectomy with adhesiolysis was suggested as the treatment option. Six months after surgery the patient had no urinary complaints and the neurological exam was normal. UI should be considered in women with urinary and neurological symptoms. A delay in diagnosis may lead to significant morbidity.

Broadening risk factor or disease definition as a driver for overdiagnosis: A narrative review

Medical overuse-defined as the provision of health services for which potential harms exceed potential benefits-constitutes a paradigm of low-value care and is seen as a threat to the quality of care. Value in healthcare implies a precise definition of disease. However, defining a disease may not be straightforward since clinical data do not show discrete boundaries, calling for some clinical judgment. And, if in time a redefinition of disease is needed, it is important to recognize that it can induce overdiagnosis, the identification of medical conditions that would, otherwise, never cause any significant symptoms or lead to clinical harm. A classic example is the impact of recommendations from professional societies in the late 1990s, lowering the threshold for abnormal total cholesterol from 240 mg/dl to 200 mg/dl. Due to these changes in risk factor definition, literally overnight there were 42 million new cases eligible for treatment in the United States. The same happened with hypertension-using either the 2019 NICE guidelines or the 2018 ESC/ECC guidelines criteria for arterial hypertension, the proportion of people overdiagnosed with hypertension was calculated to be between 14% and 33%. In this review, we will start by discussing resource overuse. We then present the basis for disease definition and its conceptual problems. Finally, we will discuss the impact of changing risk factor/disease definitions in the prevalence of disease and its consequences in overdiagnosis and overtreatment (a problem particularly relevant when definitions are widened to include earlier or milder disease).

Postpartum lumbosacral radiculopathy: a neuraxial anaesthesia complication or an intrinsic obstetric palsy?

Postpartum peripheral nerve disorders are an uncommon obstetrical complication, with most cases resulting from intrinsic obstetric palsies. We present the case of a full-term nulliparous pregnant 33-year-old woman with a vacuum-assisted vaginal delivery due to a prolonged second stage of labour and occipitoposterior position of the fetal head. For analgesia, a combined spinal-epidural technique was used. Four hours after delivery, the patient experienced a painless asymmetric motor deficit and hypoesthesia in the lower limbs, followed by sphincter disturbance. Emergent MRI was unremarkable. Electromyography showed signs of a bilateral lumbosacral radiculopathy. The patient experienced a gradual recovery over the following 2 months. Although a definitive aetiological diagnosis could not be confirmed, a lumbosacral polyradiculopathy due to intrinsic obstetric complication was considered. The patient presented several risk factors known to be associated with intrinsic obstetric palsies. Obstetricians and anaesthesiologists have an important role in preventing and diagnosing postpartum peripheral nerve disorders.

Low-grade mucinous appendiceal neoplasm mimicking an ovarian lesion: A case report and review of literature

BACKGROUND

Appendiceal tumors are rare lesions that may not be easily differentiated from primary ovarian lesions preoperatively, despite the use of advanced diagnostic methods by experienced clinicians.

CASE SUMMARY

A 59-year-old G2P2 woman, with chronic pelvic pain, underwent a pelvic ultrasound that revealed an adnexal mass measuring 58 mm × 34 mm × 36 mm, with irregular borders, heterogeneous echogenicity, no color Doppler vascularization and without acoustic shadowing. Normal ovarian tissue was visualized in contact with the lesion, and it was impossible to separate the lesion from the ovary by applying pressure with the ultrasound probe. Ascites, peritoneal metastases or other alterations were not observed. With the international ovarian tumor analysis ADNEX model, the lesion was classified as a malignant tumor (the risk of malignancy was 27.1%, corresponding to Ovarian-Adnexal Reporting Data System category 4). Magnetic resonance imaging confirmed the presence of a right adnexal mass, apparently an ovarian tumor measuring 65 mm × 35 mm, without signs of invasive or metastatic disease. During explorative laparotomy, normal morphology of the internal reproductive organs was noted. A solid mobile lesion involved the entire appendix. Appendectomy was performed. Inspection of the abdominal cavity revealed no signs of malignant dissemination. Histopathologically, the appendiceal lesion corresponded to a completely resected low-grade mucinous appendiceal neoplasm (LAMN).

CONCLUSION

The appropriate treatment and team of specialists who should provide health care to patients with seemingly adnexal lesions depend on the nature (benign vs malignant) and origin (gynecological vs nongynecological) of the lesion. Radiologists, gynecologists and other pelvic surgeons should be familiar with the imaging signs of LAMN whose clinical presentation is silent or nonspecific. The assistance of a consultant specializing in intestinal tumors is important support that gynecological surgeons can receive during the operation to offer the patient with intestinal pathology an optimal intervention.

Cervical Mesonephric Adenocarcinoma: A Case Report of a Rare Gynecological Tumor from Embryological Remains of the Female Genital Tract

INTRODUCTION

 Malignant mesonephric tumors are uncommon in the female genital tract, and they are usually located where embryonic remnants of Wolffian ducts are detected, such as the uterine cervix. The information about these tumors, their treatment protocol, and prognosis are scarce.

CASE REPORT

 A 60-year-old woman with postmenopausal vaginal bleeding was initially diagnosed with endometrial carcinoma. After suspicion co-testing, the patient underwent a loop electrosurgical excision of the cervix and was eventually diagnosed with mesonephric adenocarcinoma. She was subjected to a radical hysterectomy, which revealed International Federation of Gynecology and Obstetrics (FIGO) IB1 stage, and adjuvant radiotherapy. The follow-up showed no evidence of recurrence after 60 months.

CONCLUSION

 We present the case of a woman with cervical mesonephric adenocarcinoma. When compared with the literature, this case had the longest clinical follow-up without evidence of recurrence, which reinforces the concept that these tumors are associated with a favorable prognosis if managed according to the guidelines defined for the treatment of patients with cervical adenocarcinomas. Though a rare entity, it should be kept in mind as a differential diagnosis for other cervical cancers.

Management of pregnancy in case of multiple and giant uterine fibroids

Uterine fibroids are common among women of reproductive age. During the pregnancy, the potential complications of fibroids, although rare, are of frequent clinical concern. Available studies describing management and obstetrical outcomes in pregnant women with giant fibroids are limited. We present the case of a 39-year-old pregnant woman with multiple and large uterine fibroids. During the pregnancy, there was adequate fetal development, without major maternal complications. Given the characteristics of the fibroids and breech position of the fetus, an elective caesarean section was decided, and postpartum hysterectomy planned. This challenging obstetrical case required a multidisciplinary approach.We considered crucial discussing five main issues: preconceptional counselling, tailored pregnancy surveillance, decision of time and route of delivery, decision to perform a peripartum hysterectomy and management of decreasing blood loss perioperatively. Given the limitation of the published reports, we believe that sharing our experience, along with a literature review, is beneficial for other clinicians.

National-survey for evaluation of the best screening method of late fetal growth restriction in low risk pregnancy: A prospective study

OBJECTIVE

To compare knowledge and practices surrounding third trimester screening of fetal growth restriction (FGR) in low risk pregnancies among Portuguese Gynecologists/Obstetricians (GOs) and General Practitioners (GPs). Primary outcome was to compare the proportion of GOs that consider the need of a third trimester ultrasound (estimation of fetal weight) for screening of FGR in low risk pregnancies and the best time to perform it with the corresponding proportion of GPs.

STUDY DESIGN

We have conducted a prospective, observational cohort study based on application of surveys to GOs and GPs. Questionnaires were sent by e-mail to physicians and they filled them online. A second reminder e-mail was sent 7 days later. Recruitment was also done personally at scientific meetings. A total of 573 surveys were available for analysis, 298 corresponded to GOs and 275 to GPs. We used χ² test to compare dichotomous variables and Kruskal-Wallis test for the comparison of ordinal variables. P values <0.05 were considered statistically significant.

RESULTS

The vast majority of GOs and GPs (93%) considered that third trimester ultrasound is useful and needed for surveillance of low risk pregnancy. A higher proportion of GOs (38%) selected 35th-37th weeks as the best time to perform the ultrasound compared to GPs (10%) (p < 0.001). GOs (51%) consider that symphysis-fundus distance is a measurement with moderate accuracy for screening of FGR while GPs (61%) attribute a low accuracy (p < 0.001). Fifty percent (50%) of GOs consider that performing a third trimester ultrasound will have no impact on cesarean delivery rate for fetal distress, while 41% of GPs consider that routine ultrasound will contribute to increase this rate (p < 0.001). The majority of GPs (52%) consider that routine ultrasound will contribute to diminish the admission rate to neonatal intensive care unit while GOs revealed a dichotomy with 43% of respondents reporting that it will diminish the rate and 40% that it will have no impact.

CONCLUSION

Varied opinions among the clinicians included in our sample reflect the controversy that remains on the best screening of FGR in low risk pregnancies.