Apostolos Mamopoulos

Pravastatin improves pregnancy outcomes in obstetric antiphospholipid syndrome refractory to antithrombotic therapy

BACKGROUND Administration of conventional antithrombotic treatment (low-dose aspirin plus low-molecular weight heparin [LDA+LMWH]) for obstetric antiphospholipid syndrome (APS) does not prevent life-threatening placenta insufficiency-associated complications such as preeclampsia (PE) and intrauterine growth restriction (IUGR) in 20% of patients. Statins have been linked to improved pregnancy outcomes in mouse models of PE and APS, possibly due to their protective effects on endothelium. Here, we investigated the use of pravastatin in LDA+LMWH-refractory APS in patients at an increased risk of adverse pregnancy outcomes. METHODS We studied 21 pregnant women with APS who developed PE and/or IUGR during treatment with LDA+LMWH. A control group of 10 patients received only LDA+LMWH. Eleven patients received pravastatin (20 mg/d) in addition to LDA+LMWH at the onset of PE and/or IUGR. Uteroplacental blood hemodynamics, progression of PE features (hypertension and proteinuria), and fetal/neonatal outcomes were evaluated. RESULTS In the control group, all deliveries occurred preterm and only 6 of 11 neonates survived. Of the 6 surviving neonates, 3 showed abnormal development. Patients who received both pravastatin and LDA+LMWH exhibited increased placental blood flow and improvements in PE features. These beneficial effects were observed as early as 10 days after pravastatin treatment onset. Pravastatin treatment combined with LDA+LMWH was also associated with live births that occurred close to full term in all patients. CONCLUSION The present study suggests that pravastatin may improve pregnancy outcomes in women with refractory obstetric APS when taken at the onset of PE or IUGR until the end of pregnancy.

Acute pancreatitis in pregnancy: an overview.

Acute pancreatitis is rare in pregnancy but it is associated with increased incidence of maternal and fetal mortality. It should be considered in the differential diagnosis of upper quadrant abdominal pain with or without nausea and vomiting. The commonest identified causes of acute pancreatitis in pregnancy are gallstones, alcohol and hypertriglyceridemia. The main laboratory finding is increased amylase activity. Appropriate investigations include ultrasound of the right upper quadrant and measurement of serum triglycerides and ionized calcium. Management of gallstone pancreatitis is controversial, although laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) are often used and may be associated with lower complication rates. In hypertriglyceridemia-induced acute pancreatitis ω-3 fatty acids and even therapeutic plasma exchange can be used. We also discuss preventive measures.

Clinical Improvement and Successful Pregnancy in a Preeclamptic Patient With Antiphospholipid Syndrome Treated With Pravastatin

The clinical hallmarks of the antiphospholipid syndrome (APS) are thrombosis and adverse obstetric outcomes. Women with APS have a higher incidence of preeclampsia.1 Currently, treatment of APS focuses on anticoagulation therapy, treatment mostly given empirically and often ineffective. Similarly, treatment for preeclampsia remains symptomatic and also ineffective. Studies in animal models support the hypothesis that pravastatin may be an effective therapy to prevent pregnancy complications in APS and in preeclampsia.2–5 Here, we describe a patient, with a previous history of preeclampsia, thrombosis, and APS, presenting with preeclampsia at 23 weeks’ gestation in her second pregnancy that was treated with pravastatin, which resulted in marked clinical improvement and successful pregnancy outcome. A 30-year-old woman with no previous medical history had a first pregnancy complicated with early preeclampsia with bilateral notching (22 weeks and 0 days) and hypertension and edema at 24 weeks, leading to a still birth at week 26. She developed deep vein thrombosis 2 days postpartum. Based on her history of deep vein thrombosis, early preeclampsia, and twice positive lupus anticoagulant, with an interval of 3 months between the tests, the patient was diagnosed with APS. The patient received therapeutic doses of low-molecular-weight heparin for 3 months and prophylactic doses while trying to conceive again. Her blood pressure and proteinuria remained normal. Ten months later, she got pregnant and was started on intermediate doses of enoxaparin (0.6 OD) and aspirin (100 mg OD). Blood pressure …

Parameters affecting latency period in PPROM cases: a 10-year experience of a single institution

Abstract Objective: To investigate the association of epidemiological and pregnancy-related parameters with the latency period achieved in cases of preterm premature rupture of membranes (PPROM). Method: A retrospective study was performed enrolling cases admitted in high-risk pregnancy unit (HRPU) with PPROM between 24 + 0 and 36 + 6 gestational week during 2002–2011. Cases with vaginal bleeding at admission, co-existing maternal or fetal pathology, placenta praevia, previous interventions in cervix or uterus, triplets or higher order pregnancies were excluded. Epidemiological parameters and latency period between admission due to PPROM and delivery were recorded. Obstetrical complications, mode of delivery, and neonatal morbidity parameters were also studied. A multivariate regression model was used to correlate latency period with epidemiological and pregnancy-related risk factors. Results: Overall, there were 319 cases of PPROM admitted, of which 303 (94.9%) met inclusion criteria. Median latency period was 5.2 d. The latency interval exceeded 48 h in 65.0% of cases (197/303). Emergency cesarean was demanded in 20.2% of cases, chorioamnionitis was diagnosed in 7.5% while 76.1% of neonates were admitted in neonatal intensive care unit. Higher gestational week at admission was associated with shorter latency interval (p < 0.001), twin pregnancy with shorter latency interval (p = 0.02), while latency interval was significantly lower in cases complicated with chorioamnionitis (p = 0.048). Conclusion: Gestational week at PPROM, twin gestation and chorioamnionitis are factors significantly affecting latency interval.

Mature Ovarian Teratoma with Carcinoid Tumor in a 28-Year-Old Patient

Introduction. Coexistence of carcinoid tumor inside a mature cystic teratoma is an extremely rare phenomenon, especially in young women. We present the case of a 28-year-old woman diagnosed with a right ovarian carcinoid and treated uneventfully with conservative surgical approach. Case Report. A 28-year-old woman, gravid 0, parity 0, presented to our department for her annual gynecological examination and Pap smear test. During her examination, a mobile cystic mass was detected in the right lower abdomen. Ultrasound indicated a right ovarian mass 10.5 × 6.3 cm, confirmed by CT scan. Further investigation revealed AFP levels (1539 ng/mL). The ovarian mass was excised by laparoscopy, leaving intact the remaining right ovary. Frozen sections showed a mature cystic teratoma. However, paraffin sections revealed the presence of a small carcinoid within the teratomas gastric-type mucosa. The patient was set to a close followup. Nine months postoperatively, ultrasound pelvis imaging and CT scan of the abdomen as well as serum tumor markers have shown no evidence of recurrence disease. Conclusion. Despite the weak evidence, fertility spare surgical approach for women wanting to preserve their genital tract might be a reasonable option.

Spontaneous Postpartum Rupture of an Intact Uterus: A Case Report

Rupture of uterus is an obstetrical complication characterized by a breach in the uterine wall and the overlying serosa. We report an unusual case of spontaneous rupture of an unscarred uterus in a 33-year-old woman, a day after her third successful vaginal delivery. A 33-year-old pregnant woman, gravid 3, para 3, was referred to our department at 39 gestational week because of rupture of membranes. Despite tocolysis administration, her pregnancy was delivered vaginally after 2 days, giving birth to a male neonate of 3,020 g with normal Apgar scores at first and fifth minute. Her uterus was intact and gynecological examination after delivery was normal without any potential signs or symptoms of pathology. However, the day following her labor, patient complained of left iliac fossa pain. Her blood tests revealed a CRP value at 27.6 mg/L, whereas the X-rays revealed an extensive impacted fecal mass in the colon. MRI revealed that the left lower myometrial part of the uterus was depicted abrupt, with simultaneous presence of hemorrhagic stuff. The decision of laparotomy was therefore made in order to further evaluate rupture of uterus and properly treat patient. And subtotal hysterectomy was performed. Postoperative follow-up period was not characterized by any complications and patient was finally discharged 4 days after hysterectomy.

Congenital subclavian steal syndrome with multiple cerebellar infarctions caused by an atypical circumflex retroesophageal right aortic arch with atretic aberrant left subclavian artery

A right-sided aortic arch is a rare anomaly with an incidence of 0.1% worldwide and is usually associated with a mirror image of all supra-aortic branches or an aberrant left subclavian artery. The latter is often associated with a Kommerell diverticulum, although it can rarely be hypoplastic or atretic and lead to congenital subclavian steal. In most patients, the situation is well-tolerated. In this report, we present a case of subclavian steal syndrome with multiple cerebellar infarcts in a patient with an atypical right-sided aortic arch and an atretic aberrant left subclavian artery arising from a left-sided descending thoracic aorta.

Active sacral neuromodulator during pregnancy: a unique case report.

Sacral neuromodulation with an implanted device is used in patients who experience urinary retention and malfunctioning overactive bladder where conservative treatment is not sufficient. The knowledge of its effect on pregnancy is not known. This article presents the case of a 34-year-old pregnant woman with an implanted device, the use of which was not discontinued during her pregnancy. Full-term pregnancy was achieved, and a healthy child was delivered by cesarean section. Sacral neuromodulation during pregnancy appears to be safe and may be preferable to intermittent bladder catheterizations that increase the chance of urinary infections.

Large luteinized follicular cyst of pregnancy.

A large (165 × 235 × 250 mm) solitary, unilocular cyst with a thin, smooth wall and homogeneous anechoic content was detected during a routine ultrasound scan at 24 weeks of gestation in an asymptomatic 39‐year‐old woman with a singleton pregnancy. The cyst was aseptate, lacked mural blood flow and was not associated with ascites. It was located in the central abdominal area above and anterior to the uterus. Gradually increasing abdominal discomfort developed, and a laparotomy was performed at 27 weeks; the cyst was removed after aspiration of 6.3 L of serous fluid and the ipsilateral ovary was preserved. Pathological examination indicated a large luteinized follicular cyst of pregnancy. A healthy male infant was delivered vaginally at term. A rapidly enlarging ovarian mass in pregnancy poses significant diagnostic problems. Large luteinized cysts of pregnancy are uncommon and thought to involve stimulation by human chorionic gonadotropin (hCG), or increased tissue sensitivity to hCG. A literature search identified four previous cases that had been detected prenatally. With one exception, the cysts appeared to enlarge during pregnancy, eventually becoming symptomatic, and two previous cases also required removal of the cyst before birth. Adverse pregnancy outcome was only reported in one of the previous cases. In summary, large luteinized cysts of pregnancy are an uncommon type of cystic mass particular to pregnancy, characterized by the combination of a benign appearance and a tendency to enlarge rapidly, eventually becoming symptomatic and most often necessitating surgery. Copyright

Postpartum mesenteric, splenic and portal vein thrombosis

platelets (Solanki et al. 1986). The widespread splenic infarction was secondary to the increased intrasplenic pressure preventing adequate arterial perfusion. Venous thrombosis formation is a multi-hit phenomenon, with often several risk factors combining together to bring about a clinical event. In our case, acquired risk factors included the postpartum period, caesarean section, immobilisation and dehydration from postoperative vomiting. Thrombophilia tests performed postnatally were negative Laboratory investigation in superior mesenteric vein thrombosis is non-specific and radiological examination is the key to the diagnosis. Plain X-ray films can rule out perforated viscus and may reveal small bowel obstruction. CT angiogram is the preferred modality, revealing thrombosis with a sensitivity of 90%. Management is usually conservative, aimed at adequate hydration, analgesia, blood transfusion and anticoagulation with therapeutic doses of unfractionated or low molecular weight heparin. Laparotomy may be indicated if there are signs of peritonitis. The role of exchange transfusion remains unclear but in this patient, there was little evidence of active sickling, with a normal lactate dehydrogenase and no increase in reticulocyte count above baseline. Microvascular occlusion and resulting tissue ischaemia is a hallmark of sickle cell disease. The significance of large vessel thrombosis has only recently been mentioned in the literature and the involvement of large veins has seldom been stressed. Yet thrombosis of the cerebral venous sinuses and in particular that of the superior sagittal sinus are known complications (Sarnaik et al. 1979; Ross et al. 1974). Superior mesenteric vein thrombosis has been described in two patients but not in pregnancy on the post natal period (Warshauer et al. 2001; Arnold et al. 1993). The sickled erythrocyte–endothelial adhesions could be occurring in large vessels and could contribute to endothelial injury, vascular intimal hyperplasia and thrombosis (Francis and Johnson 1991; Francis 1991). It has been suggested that the vulnerability of the splenic and cerebral circulation may be related to the large proportion of cardiac output they receive (Powars 1990). Acute splenic sequestration is a rare finding in adults and this may, in part, be due to under diagnosis. This case demonstrates the difficulty in diagnosing such cases. Abdominal CT aids early detection and prompt treatment that should involve a multidisciplinary team approach. Underlying venous thrombosis should be considered, as anticoagulation may be an important addition to the treatment. This case highlights the risk of splenic sequestration in adult patients with sickle cell variants and emphasises the possibility of venous thrombosis as an underlying mechanism in this disorder. It also raises awareness of the increased thrombotic risk of patients with sickle cell disease undergoing delivery, even when on thromboprophylaxis.