Felipe Favorette Campanharo

Diagnosis of Heterotopic Pregnancy Using Ultrasound and Magnetic Resonance Imaging in the First Trimester of Pregnancy: A Case Report

Heterotopic pregnancy is a condition characterized by implantation of one or more viable embryos into the uterine cavity while another one is implanted ectopically, particularly into the uterine tube. Its occurrence has increased drastically over the last few years due to assisted reproduction procedures. In general, the diagnosis is made during the first trimester by using endovaginal two-dimensional ultrasound (2DUS), through observing a complex para- or retrouterine mass in association with a viable uterine pregnancy. However, under some conditions such as atypical ultrasonographic presentations, 2DUS does not clarify the situation whereas magnetic resonance imaging (MRI) of the pelvis is able to do so. We present the case of a pregnant woman in her fifth pregnancy, with a clinical condition of lower abdominal pain and pallor. Endovaginal 2DUS showed a complex voluminous mass in the left pelvic region in association with a viable intrauterine pregnancy. 2DUS in power Doppler mode showed “ring” vascularization, compatible with an ectopic gestational sac. MRI was of great importance in that it suggested that the mass had hematic content, which together with the clinical features, indicated that laparotomy should be performed. This surgical choice was essential for the woman to achieve a clinical improvement and for good continuation of the intrauterine pregnancy.

The Impact of Cardiac Diseases during Pregnancy on Severe Maternal Morbidity and Mortality in Brazil.

Background To evaluate maternal heart disease as a cause or complicating factor for severe morbidity in the setting of the Brazilian Network for Surveillance of Severe Maternal Morbidity. Methods and Findings Secondary data analysis of this multicenter cross-sectional study was implemented in 27 referral obstetric units in Brazil. From July 2009 to June 2010, a prospective surveillance was conducted among all delivery hospitalizations to identify cases of severe maternal morbidity (SMM), including Potentially Life-Threatening Conditions (PLTC) and Maternal Near Miss (MNM), using the new criteria established by the WHO. The variables studied included: sociodemographic characteristics, clinical and obstetric history of the women; perinatal outcome and the occurrence of maternal outcomes (PLTC, MNM, MD) between groups of cardiac and non-cardiac patients. Only heart conditions with hemodynamic impact characterizing severity of maternal morbidity were considered. 9555 women were included in the Network with severe pregnancy-related complications: 770 maternal near miss cases and 140 maternal death cases. A total of 293 (3.6%) cases were related to heart disease and the condition was known before pregnancy in 82.6% of cases. Maternal near miss occurred in 15% of cardiac disease patients (most due to clinical-surgical causes, p<0.001) and 7.7% of non-cardiac patients (hemorrhagic and hypertensive causes, p<0.001). Maternal death occurred in 4.8% of cardiac patients and in 1.2% of non-cardiac patients, respectively. Conclusions In this study, heart disease was significantly associated with a higher occurrence of severe maternal outcomes, including maternal death and maternal near miss, among women presenting with any severe maternal morbidity.

Microcirculation Approach in HELLP Syndrome Complicated by Posterior Reversible Encephalopathy Syndrome and Massive Hepatic Infarction

HELLP syndrome is a complication of severe forms of preeclampsia and occurs mainly in the third trimester of pregnancy. In extreme cases, it may evolve unfavorably and substantially increase maternal mortality. We present the case of an 18-year-old pregnant woman who was admitted to our emergency service in her 31st week, presenting with headache, visual disturbances, and epigastralgia, with progression to a severe condition of HELLP syndrome followed by posterior reversible encephalopathy syndrome (PRES) and hepatic infarction. We highlight the approach taken towards this patient and the case management, in which, in addition to the imaging examinations routinely available, we also used the sidestream dark field (SDF) technique to evaluate the systemic microcirculation.

Guillain-Barré Syndrome after H1N1 Shot in Pregnancy: Maternal and Fetal Care in the Third Trimester—Case Report

Guillain-Barré syndrome is a rare neurological disease of progressive installation, usually following a previous acute infectious state, has a rare incidence, especially in pregnancy, and can induce major complications and high mortality risk. Its occurrence, after immunization to influenza during the last trimester pregnancy, has not been reported before. We presented a case of a 36-year-old pregnant woman that was immunized to H1N1 in the last trimester; 10 days later she developed shoulder and lumbar spines pain, limbs weakness and facial paralysis with unfavorable clinical evolution and was submitted to intensive therapy care. We described clinical and obstetrical approach, pointing out peculiarities involved in this pathology in pregnancy.

Challenges in congenital central hypoventilation syndrome (Ondine’s curse) on pregnancy: a case report

Renato Teixeira Souza, Felipe Favorette Campanharo, Edward Araujo J unior, Gustavo Antonio Moreira, Diego Robles Mazzotti, Rosiane Mattar, Antonio Fernandes Moron and Fernando Morgadinho Santos Coelho Department of Obstetrics, Paulista School of Medicine – Federal University of S~ao Paulo (EPM-UNIFESP), S~ao Paulo-SP, Brazil; Department of Psychobiology, Paulista School of Medicine-Federal University of S~ao Paulo (EPM-UNIFESP), S~ao Paulo-SP, Brazil; Discipline of Neurology, Paulista School of Medicine-Federal University of S~ao Paulo (EPM-UNIFESP), S~ao Paulo-SP, Brazil

Complex regional pain syndrome and pregnancy

A 37-year-old patient with Complex Regional Pain Syndrome(CRPS) and continuous intrathecal morphine administration presents to prenatal care pregnant with 16 weeks’ gestation. Besides CRPS, she has other medical conditions like obesity, migraine and angina, using topiramate and diltiazem. The discussion goes through an overview of CRPS and chronic pain management in pregnancy. In the end, we include a summary and recommendations based on a brief review of the literature. Correspondence to: Felipe Favorette Campanharo, Federal University of São Paulo Department Obstetrics, Brazil, E-mail: favorette@hotmail.com

Sigmoid volvulus during pregnancy with endoscopic treatment.

Case report Sigmoid volvulus is a rare surgical complication that may occur in pregnancy and during the puerperium. Th e incidence of intestinal obstruction during gestation ranges from 1 in 1,500 to 1 in 66,431 births (Perdue et al. 1992). In a literature review analysing 66 cases, intestinal obstruction occurred in 53 patients during pregnancy and in 13 patients during the puerperium, with 44 patients presenting specifi c symptoms such as abdominal pain (98%), vomiting (82%) and constipation (30%). In the same study, the leading cause of intestinal obstruction complicating pregnancy and the puerperium was adhesions (59%), followed by volvulus (23%) and intussusception (5%); the most frequent location of the volvulus was the sigmoid colon. Other causes included hernia (3%), carcinoma (1%), appendicitis (1%) and idiopathic cases, accounting for 8% (Perdue et al. 1992). Endoscopy is used for diagnostic as well as therapeutic purposes; fi ndings include obstruction, usually 20 – 30 cm from the anal verge; and the mucosae may be healthy or show signs of ischaemia, with congestion and violaceous colouration. Th e presence of dark spots may suggest necrosis (Lal et al. 2006). Clinical treatment consists of volaemic and electrolyte replacement and antibiotic prophylaxis (Perdue et al. 1992). A 24-year-old patient, 4 gravida, 4 para (4 c-sections) presented the following symptoms on the third postpartum day: pain and abdominal distension, nausea, vomiting and no elimination of gas and faeces for 3 days. On physical examination, the patient was dehydrated and haemodynamically stable but had tachycardia. Th e abdomen was distended, diff usely painful on palpation and exhibited diff use tympanism to percussion, with increased hydro-aerial sounds, no signs of peritonitis and with surgical incision in good condition; rectal examination showed rectal ampulla to be empty. Laboratory examinations showed discrete leucocytosis (15,100 cells/mm 2 ) and increased evidence of infl ammation (C-reactive protein: 102 mg/dL). Th e results of the other laboratory examinations were the following: haemoglobin – 11.2 g/dL, haematocrit – 31.5%, platelets – 272,000/mm 2 , pH – 7,37, arterial lactate – 11 mg/dL and normal renal function. Abdominal radiography exhibited signifi cant colonic distension compatible with the ‘ inverted U shape ’ or the ‘ coff ee bean sign ’ (Figure 1). A computed tomography (CT) scan of the abdomen and pelvis was performed and showed accentuated distention of the colon segment in a closed loop, with apparent twisting of the sigmoid mesocolon, inferring a sigmoid volvulus without signs of perforation or vascular complications. Th e treatment chosen was supported with rehydration and antibiotics, followed by rigid rectosigmoidoscopy with number 30 rectal probe allocated 10 cm from the anal verge. Th e patient exhibited clinical improvement and returned to eliminating fl atus and bowel movements and lower abdominal distension decreased. An abdominal X-ray performed as a control showed decreased colonic distention. Rigid rectosigmoidoscopy, aft er the procedure, showed slightly hyperaemic mucosa, with no signs of necrosis, and the probe was removed. Th e patient progressed well and was discharged on 3rd postoperative day. Postpartum diagnosis of the reason for acute abdominal pain is diffi cult, considering the increased abdominal circumference and diffi culty in elucidating abdominal signs due to the loss of tonus in the abdominal wall, which may mask the signs of peritonitis (Sascha Dua et al. 2007; Kolusari et al. 2009). However, sigmoid volvulus is also the most common cause of intestinal obstruction during pregnancy, accounting for 25% – 44% of the cases because the enlarging uterus can cause a redundant or abnormally long sigmoid colon to rotate around its point of fi xation on the sigmoid mesocolon or the pelvic side wall and should always be considered as one of the causes of acute intestinal obstruction during pregnancy (Kumar et al. 2014). In simple abdominal radiography, characteristic fi ndings are disproportionate enlargement of the sigmoid colon as well as twisting of the sigmoid colon around itself, leading to gas build-up in the colon, which extends from the pelvis to the upper right quadrant of the abdomen, next to the diaphragm, known as the ‘ inverted U ’ or the ‘ coff ee bean sign ’ (Lal et al. 2006). CT of the abdomen and pelvis can be helpful in identifying the cause and location of obstructions, resulting from other diseases and also in assessing consequent ischaemia due to strangulation of bowel loops. During the pregnancy, magnetic resonance imaging has demonstrated the same potential of X-ray to identify the ‘ coff ee bean sign ’ (Palmucci et al. 2014). In this case, the sigmoid volvulus may have occurred due to mobility of the colon combined with a distortion of the sigmoid, associ© 2015 Taylor & Francis Group, LLC ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2015.1060208

Amniotic embolism with complement activation in a lupic pregnant woman.

Descemet ’ s tear and hyphaema (Jain et al. 1980; Bergen and Margolis 1976). Th e described posterior segment complications are retinal haemorrhages, Purtscher retinopathy, macular hole, choroidal rupture and traumatic optic neuropathy (Jain et al. 1980; Casillas et al. 2010; Osmundson and Giangiacomo 1999). Retinal haemorrhage is the most common injury associated with birth trauma (Jain et al. 1980). With the decrease in incidence of instrumental vaginal deliveries, these forceps-related ocular complications are less frequently reported now (Dupuis et al. 2003). There are few complications which can be managed conservatively, but severe ocular injuries need specialist care and surgical intervention (Holden et al. 1992). A GRT is defi ned as a full-thickness retinal break involving more than 3 clock hours (90 ° ) of the retina associated with posterior vitreous detachment. Giant tears result from sudden transverse distension of the globe as it is compressed anteroposteriorly during trauma (Duguid and Leaver 2000). The same mechanism might have caused GRT in the present case. Retinal reattachment surgeries in these cases with silicone oil tamponade needs post-operative prone positioning for 14 – 16 h a day for 3 weeks, which is difficult for children to maintain. The integrity of these eyes can be achieved anatomically; however, functional outcome is difficult to obtain especially following severe trauma and in eyes which require repeated surgeries. These eyes are prone to develop phthisis bulbi despite best efforts and amblyopia is of major concern for visual improvement in these children even if the injured eye has been salvaged anatomically (Meier 2010). Sympathetic ophthalmia, an autoimmune variety of panuveitis, characterised by inflammation of the uveal tract of the contralateral uninjured eye may occur later in this child because of the insult to the uveal tissue of the injured eye. The onset may be delayed for years necessitating lifelong management for these children (Chu and Chan 2013). A thorough English language literature search did not reveal any report of a case with GRT and corneal tear following obstetric forceps delivery. Th is report highlights hitherto unreported severe ocular complication of forceps injury which has a long-term bearing on the visual status of the aff ected eye. Th e obstetricians should be very careful while performing instrument-assisted deliveries to avoid such devastating visual complications.

Diagnosis of ovarian metastasis from gestational trophoblastic neoplasia by 3D power Doppler ultrasound and dynamic contrast-enhanced magnetic resonance imaging: case report.

Choriocarcinoma is a highly malignant disease of trophoblastic cells, which affects young women in the reproductive years. The main sites of metastasis from choriocarcinoma are lung, vagina, liver, gastrointestinal tract and kidneys, and the involvement of the ovaries is extremely rare. The diagnosis of ovarian metastasis is made mainly by two-dimensional ultrasonography (2DUS) with color Doppler, which shows a large vessel in the center of the mass. The three-dimensional power Doppler ultrasound (3D power Doppler) and dynamic contrast-enhanced magnetic resonance imaging (MRI) are new diagnostic modalities not yet published in literature. We report a case of metastatic choriocarcinoma with left ovary involvement in a 48-year-old woman with history of molar pregnancy and irregular follow-up of this disease. We emphasize the main findings by 2DUS with color Doppler, 3D power Doppler and dynamic contrast-enhanced MRI. 3D power Doppler is able to improve the assessment of anatomical relationships of vessels with the ovarian mass, while the resonance angiography allows us to evaluate the anatomic relations of the mass and adjacent structures, as well as the iliac vessels. The 3D power Doppler and dynamic contrast-enhanced MRI are promising methods in the evaluation of metastasis arising from gestational trophoblastic tumors.