B. Caspi

The onion skin sign: a specific sonographic marker of appendiceal mucocele.

Objective. To evaluate the association of the onion skin sign as a sonographic marker for appendiceal mucocele. Methods. The sonographic onion skin sign was considered specific for the preoperative diagnosis of appendiceal mucocele. Therefore, detection of this sign in a mass located in the right lower abdomen, unrelated to the female reproductive organs, indicated surgical intervention with a presumptive diagnosis of appendiceal mucocele. From 1998 through 2001, female patients who were found to have atypical cysts containing this sign underwent surgery. The cases were closely followed, and intraoperative findings and final histologic diagnoses were recorded. Results. Appendiceal mucocele was the final diagnosis in all 7 patients in whom the onion skin sign was observed. One additional patient had an appendiceal mucocele with a sonographic picture of a clear tubular cystic structure. Conclusions. A sonographically layered cystic mass in the right lower quadrant of the abdomen in the presence of a normal ovary strongly suggests the diagnosis of appendiceal mucocele. Recognition of the sonographic onion skin sign in a cystic mass in the right lower quadrant may facilitate the accurate preoperative diagnosis of appendiceal mucocele.

Spontaneous ovarian hyperstimulation syndrome concomitant with spontaneous pregnancy in a woman with polycystic ovary disease

Ovarian hyperstimulation syndrome has been described after treatment with exogenous gonadotropins, clomiphene citrate, and gonadotropin-releasing hormone. Spontaneous ovarian hyperstimulation syndrome has not been described before, except in association with hypothyroidism. We report on a case associated with spontaneous pregnancy, occurring in a woman with polycystic ovary disease.

Isolated tubal torsion : clinical and ultrasonographic correlation

A 13 year old girl developed sudden onset of left lower abdominal pain 30 hours prior to arrival. She previously had enjoyed perfect health, and menarche had occurred 3 months before the current episode. Family history was unremarkable, and no history of previous abdominal pain was elicited. After the onset of left abdominal pain, the pain assumed a colicky nature accompanied by nausea and vomiting. No urinary symptoms were encountered, and the patients temperature was normal. On examination, an ill-appearing girl with slight tachycardia of 92 beats per minute was encountered. Tanner pubertal development of grade III was assigned. The abdomen was soft to palpation, and no outright signs of peritoneal irritation were elicited, although some voluntary guarding in the left lower quadrant was noticed. On pelvic examination per rectum, labia and

Unsuspected uterine leiomyosarcoma discovered during treatment with a gonadotropin-releasing hormone analogue: A case report and literature review

We report a case of a 37-year-old woman who had received five courses of gonadotropin-releasing hormone (GnRH) agonist (Decapeptyl) for presumed uterine leiomyomata associated with episodes of uterine bleeding. Submucous myoma (histologically proven) was partially removed on the first visit. After a period of significant reduction in the tumor size and cessation of uterine bleeding, the symptoms recurred along with rapid re-growth of the uterus. Total abdominal hysterectomy was performed and the pathologic evaluation revealed leiomyosarcoma with a high mitotic rate. This case and the literature review emphasize the problems encountered with the early diagnosis of uterine leiomyosarcoma during GnRH agonist therapy.

Non-aggressive management of post-date pregnancies

A non-aggressive approach to the management of post-date pregnancies was tested in a clinical trial involving 156 patients who had reached 294 days of amenorrhea and had a pelvic score of 4 or less. Dates had been established with certainty in each case. In half of the patients (the study group) no time limit was imposed on the pregnancy, but the women were checked at frequent intervals for any increase in pelvic score and for changes in any of the following: fetal movement count recorded daily by the mother, an oxytocin challenge test, and amnioscopy. The pregnancy ended either through spontaneous contractions or through surgical induction carried out because of a change in any one of the parameters or an increase above 4 in the pelvic score. In the 78 control patients labor was induced surgically on day 294, even if the pelvic score was low. In the study group, labor started spontaneously in 52 patients; labor was induced in 17 women after they showed an elevated pelvic score, in 7 because of a pathologic parameter and in one because a mild pre-eclampsia developed. There were 7 cesarean sections in the study group compared with 16 in the control group (P less than 0.05). The average duration of labor was 6.7 h in the study group, compared with 9.4 h in the control (P less than 0.01). There was no significant difference between the two groups with regard to meconium staining during labor, pathologic fetal heart rate, or the 5 min Apgar score. In the study group there was one neonatal death as a result of severe congenital heart disease, and in the control group one infant died due to asphyxia. It is concluded that conservative management of prolonged pregnancies, with close supervision, gives better results than routine induction of labor at 42 wk. The importance of the pelvic score as an indication for induction is stressed. A protocol has been developed which can be used in cases of uncertain dates as well.

Invasive mole and placental site trophoblastic tumor : two entities of gestational trophoblastic disease with a common ultrasonographic appearance

Gestational trophob1astic disease (GTD) is a proliferative disease of the trophoblast that may be manifested as a relatively benign form, hydatidiform mole (HM), or as the more malignant forms, invasive mole (IM) or choriocarcinoma (CCA). IM is defined by the presence of molar villi beyond the site of initial implantation (i.e., in the myometrium or at distant sites). Current pathologic practice recognizes three diagnostic categories of GTD: HM, CCA and placental site trophoblastic tumor (PSTT). Molar villi characterize HM; CCA and PSTT are avillous. PSTT of the uterus is the rarest form of GTD. The distinction between this tumor and CCA rests mainly on the microscopic appearance. The predominant cell in PSTT is intermediate trophoblastic cell. The cellular population is predominantly monomorphic, as opposed to the mixture of cell types in other forms of GTD. Pathologic examination combined with human chorionic gonadotropin (hCG) and human placental lactogen (hPL) assays are the cornerstone for diagnosis. We describe a case of IM and a case of PSTT, both invading the uterine wall. They share a similar ultrasonographic appearance; to the best of our knowledge this is the first sonographic description of PSTT.

Ultrasonic prediction of growth discordancy by intertwin difference in abdominal circumference

Intertwin abdominal circumference (AC) and femur length (FL) differences were studied in 24 growth‐discordant (⩾15% birth weight difference) and in 32‐growth concordant twin pairs delivered within 2 weeks of the last ultrasonic examination. Both groups were of similar gestational age but differed significantly in the mean twin birth weight and intertwin AC difference (P = 0.01 and P = 0.00009, respectively). A cutoff value (⩾18 mm) for AC difference was found to discriminate significantly (P < 0.0009) between concordant and discordant pairs with sensitivity, specificity, positive predictive value and negative predictive value of 66.7%, 78%, 69.5% and 75.7%, respectively. These data may suggest that an intertwin difference of 18 mm or more in AC effectively screens for the diagnosis of 15% or more birth weight difference in twin pregnancies.

Aspiration of Simple Pelvic Cysts during Pregnancy

Traditional management of persistent ovarian cysts in pregnancy is explorative laparotomy at 16–20 weeks of gestation and resection of the tumor. Scheduling surgery to this time of pregnancy is accepted in order to prevent abortions that are common whenever surgery is done in the first trimester, without delaying treatment of ovarian tumors which harbor a malignant potential. In the following article we report of 10 cases where simple ovarian cysts diagnosed during pregnancy were successfully treated by sonographically guided cyst aspiration. This new approach is justified with no fear of missing a malignant ovarian tumor due to strict ultrasonic characteristics of benign cysts that include unilocular simple appearing cyst with no solid echogenic parts, septations or papillary structures. For 5 of the 10 women undergoing aspiration, this constituted the definitive treatment, while the remaining 5 were later operated. We conclude that aspiration of simple cysts during pregnancy is safe, may save surgical intervention and in some cases this will be the definitive treatment.

Safe epidural anesthesia performed during labor by an obstetrician

One thousand seven hundred eighty‐seven epidural anesthesias during labor were performed by obstetricians well trained in the technique by the anesthesiology department. The course of labor was accelerated compared to control group. Vacuum extraction rate was 11.9%. Fetal outcome was favorable. Incidence of major complications was 0.16%. We conclude that in countries where an anesthetist is not routinely available at delivery wards, a safe and efficient epidural anaesthesia could be performed by an obstetrician well trained in administration of epidural anesthesia.

Declining β-human chorionic gonadotropin level may provide false security that tubal pregnancy will not rupture

Two patients with declining serum concentrations of beta-human chorionic gonadotropin (beta-hCG) and a ruptured tubal pregnancy with hemoperitoneum are described. Declining beta-hCG does not rule out the possibility that the ectopic pregnancy will rupture.