Dubravko Habek

Massive Labia Minor Hypertrophy Following Vulvar Edema and Abscess in Pregnancy - Case Report

A rare case is presented of vulvar edema and abscess with subsequent labia minor hypertrophy in a 26-year-old woman, which developed during two consecutive pregnancies with normal maternal and neonatal outcome. After a first pregnancy, the patient was initially treated conservatively, followed by incision of the abscess. After the second pregnancy, surgical correction of the hypertrophic labia minor was performed. The possible causes, complications and therapeutic options are discussed.

Tuboovarian abscess mimicking intraligamentar uterine myoma and a intrauterine device : A case report

A case study is presented of tubo-ovarian abscess (pathohystological-verified actinomycosis) in a 41-year-old woman with an intrauterine device (IUD), which on US was found to be imposed upon an intraligamentary degenerated myoma (pyomyoma). The patient was afebrile, with normal vital functions (diuresis, blood pressure and pulse). Exposure of the abdominal cavity by lower transverse laparotomy performed under general endotracheal anaesthesia revealed slight uterus enlargement with normal left adnexa, whereas right adnexa were not exposed due to the soft tumour in the region of the right ligamentum latum, which displaced the urinary bladder and uterus leftward. The peritoneum fold was incised and deprepared, revealing a tumorous formation imposed onto the myoma or onto the ‘cold’ tubo-ovarian abscess. Total hysterectomy was then performed. Left adnexa showed a normal finding. Hemalaun-eosin staining of the preparation of the tumour capsule and tumour content showed colonies of threads extending radially to the surrounding tissues (drusen), surrounded by pus corpuscles, polymorphonuclears and macrophages containing lipids (sulfur granules). The patient was free from disease relapse at 2 years after the procedure. Thus, total abdominal hysterectomy and salpingoophorectomy, along with antibiotic therapy, were the definite mode of treatment for pelvic actinomycosis.

Spontaneous pregnancy during ulipristal acetate treatment of giant uterine leiomyoma

Ulipristal acetate, a progesterone receptor modulator, pharmacologically inhibits endometrial proliferation and thereby prevents pregnancy. It is primarily used as emergency contraception, but also for the treatment of fibroids in women of reproductive age. There have been no published cases of pregnancy, while on therapy with ulipristal acetate.

An Unusual Case of Infertility: Urethral Coitus Due to Cribriform Hymen

Urethral coitus is a rare type of sexual practice, usually due to vaginal agenesis or hymeneal anomalies. We report a case of urethral coitus in a healthy couple who were evaluated for infertility. The female partner had cribriform hymen and dilated urethral orifice but did not report any problems except infertility and her genital anatomy was normal. The male partner reported concerns over his penile size but was otherwise healthy. After incision of hymen, they were able to have vaginal coitus and successfully conceived. While urethral coitus is rare, it should be suspected in women presenting with infertility and a dilated urethral orifice.

Acute Abdomen Syndrome Due To Spontaneous Intraperitoneal Bladder Rupture Following Vaginal Delivery

We report a rare case of spontaneous intraperitoneal bladder rupture following normal vaginal delivery without concomitant uterine rupture. Key diagnostic clinical features were acute renal failure, new-onset ascites and bowel ileus with urosepsis. Laparotomy and bladder repair with omentum patch were performed with no adverse outcome reported.

Intraoperative Spontaneous Rupture of Uterine Varicose Vein

Spontaneous, non-traumatic rupture of pelvic (uterine) varicose veins in pregnancy and delivery is a very rare and unpredictable complication associated with a high maternal morbidity and mortality of up to 30% due to hemoperitoneum and hemorrhagic shock. Clinically, rupture of pelvic (uterine) varicose vein mostly mimics placental abruption or uterine rupture1-3. In a 35-year-old tertipara free from comorbidity, repeat elective cesarean section in spinal anesthesia was performed in 39th week of gestation because of previous two cesarean sections and transverse fetal lie. Th e procedure proceeded uneventfully, a healthy, eutrophic neonate was born, and there were no intraabdominal adhesions. During hysterotomy suture, there was constant effl ux of dark blood from the left iliac fossa. Th erefore, the uterus was exteriorized to reveal a varicose tubo-ovarian conglomerate at a broad, perforated, abundantly bleeding varicocele posteriorly, adjacent to the uterus. Considering this fi nding and inability to place sutures along with the oxidized cellulose strip just placed on the vein, which was fragile and breakable, left-sided adnexectomy was performed. However, there was massive bleeding also from descending varicose uterine veins (pelvic varicocele), therefore sutures according to O’Leary were made, but failed due to varicose vein breaks. Hemostatic sutures were placed for bleeding from uterine edges, but abundant bleeding continued. Because of uncontrollable hemorrhage, maternal age and multiparity, total hysterectomy with adequate hemodynamic replacement was performed, upon the patient’s consent. Th e postoperative course was normal and the patient was discharged from the hospital on the fi fth day of the puerperium. Varices of the broad ligament, superfi cial uterine veins and utero-ovarian ligament have been described in several case reports3,4. Urgent laparotomy is indicated for vital indications, with hemostasis by ligature (uterine or internal iliac artery ligation), oxidized cellulose, or rarely hysterectomy, thereby respecting maternal age, parity, site and intensity of bleeding, shock development2, as in the case of uncontrolled bleeding presented. A recently reported case of percutaneous embolization of ruptured varicocele is an option of conservative treatment aiming at uterus preservation5, which requires trained interventional radiology team, which was not available in our hospital at that time.

Bilateral Ovarian Torsion during Follow-up for Antenatally Detected Ovarian Cysts

Ovarian torsion is a surgical emergency demanding timely diagnosis and treatment to prevent loss of the ovaries which if happens may result in functional and emotional consequences. Simple (less than 5cm in size) ovarian cysts require follow-up for potential self-resolution. We describe a case of antenatally detected bilateral ovarian cysts that developed bilateral ovarian torsions on follow-up, postnatally.

Prenatal Diagnosis of a Fetal Epidural Hematoma.

A fetal epidural hematoma is a rare finding during the prenatal period, with different etiologies such as maternal trauma, infections, or maternal use of specific medications such as warfarin. Both ultrasonography and magnetic resonance imaging (MRI) have been used successfully to evaluate the fetal central nervous system. Although these methods are also useful in detecting and evaluating a fetal epidural hematoma, brain function of the neonate cannot be exactly predicted on the basis of the prenatal findings. According to the literature data to date, this is the first reported case of prenatally detected fetal epidural hematoma of unknown etiology with a good outcome.

Fatal, spontaneous, unknown aortal aneurysm dissection in a woman of 38 weeks’ gestation

We describe a case of spontaneous dissection of an unknown ascendingthoracic aortic aneurysm in a 35year-old woman in her 38th week of pregnancy, resulting in an atypical clinical picture, emergency caesarean section, and lethal outcome in both the mother and child.

Bilateral Fetal Hexadactyly Combined with Transient Dacryocystocele.

Fetal polydactyly/hexadactyly, a supernumerary or rudimentary finger present on one or either fetal hands or feet, could be a sign of an underlying chromosomal aberration like trisomy 18 or 13, so in cases when hexadactyly is detected prenatal karyotyping is recommended. A supernumerary finger could be located on either side of the hand (radial or ulnar) or somewhere in between. Furthermore, it is also part of other malformation syndromes, like Meckel-Gruber or Ellis-vanCreveld syndrome. However, hexadactyly could be an isolated anomaly found prenatally in fetuses with a normal karyotype and with no other additional anomalies, and is even inheritable in some families. The manner of postnatal treatment of hexadactyly depends on how developed this supernumerary finger is. Dacryocystocele is a rare condition that could be detected prenatally mostly during the third trimester of gestation. It is a fluid-filled structure caused by obstruction of the lacrimal drainage system and could be easily visualized by 2D ultrasound as an anechoic cystic structure positioned inferior and medial to the orbit. Three-dimensional (3D) multiplanar and surface views facilitate prenatal diagnosis. In many cases dacryocystocele resolves spontaneously, even prenatally, but mostly in the early neonatal period (Sharony R et al. Ultrasound Obstet Gynecol 1999; 14: 71–73 and Sepulveda W et al. J Ultrasound Med 2005; 24: 225–230).