Kwei-Shuai Hwang

RECURRENT ECTOPIC PREGNANCY IN THE IPSILATERAL OVIDUCT AFTER PRIOR LAPAROSCOPIC PARTIAL SALPINGECTOMY

Ectopic pregnancy occurs in approximately 2% of all pregnancies, and over 95% of ectopic pregnancies involve the oviduct. Ectopic pregnancy remains the major cause of first-trimester maternal death [1]. Tubal surgery is reported to be the greatest risk factor for ectopic pregnancy. Other important risk factors include a previous ectopic pregnancy, in utero diethylstilbestrol exposure, pregnancy with an intrauterine device in situ, documented tubal pathology, infertility, previous genital tract infection, and a history of multiple sexual partners [2]. Transvaginal ultrasonography has proven to be indispensable in the early diagnosis and localization of ectopic pregnancies [3]. Even in the absence of abnormal symptoms, patients with a history of prior ectopic pregnancies should undergo thorough transvaginal ultrasonography examinations when the confirmed pregnancies are detected. Here, we report a rare case of a patient with a recurrent ectopic pregnancy in the ipsilateral oviduct after prior laparoscopic partial salpingectomy. A 28-year-old, gravida 1, para 0, woman using no contraception presented to the emergency department, complaining of severe lower abdominal pain and vaginal bleeding that had lasted 5 hours. Five years earlier, the patient had undergone laparoscopic left partial salpingectomy for an ectopic gestation. The patient’s blood pressure was 97/55 mmHg and her pulse was 97 beats/min. Her abdomen was diffusely tender with rebound. A urine pregnancy test result was positive and her hemoglobin was 10.0 g/dL. A transvaginal sonogram demonstrated a 2 × 3 cm heterogeneous left adnexal

Female Acute Urinary Retention Caused by Anterior Deflection of the Cervix Which Was Augmented by an Uterine Myoma

Acute urinary retention rarely affects women of reproductive age, because it is an anatomic peculiarity. The incidence of acute urinary retention is only 7 in 100,000 persons per year [1]. The most common causes of obstructive retention are gynecologic surgery and pelvic masses. We herein report a case of acute urinary retention caused by impaction by a uterine myoma. The patient was a 45-year-old, gravida 3, para 2, woman with regular menstrual cycles, who presented to the gynecologic clinic with a 1-year history of intermittent urinary retention. If she prolonged the time between voidings, bladder emptying became difficult. However, she always voided with a strong Valsalva maneuver and had to void every 3–4 hours to prevent urinary retention. The patient noted her first episode of urinary retention in May 2006. When she attempted to void, she was unable to initiate voiding despite standing, or using the Valsalva maneuver, suprapubic pressure or digital manipulation of the cervix. She went to the emergency room where Foley catheterization was performed, and 1,000 mL of urine was drained. She had several more episodes of retention requiring catheterization over the next 6 months. Acute urinary retention was noted when she came to our gynecologic clinic. Physical examination revealed that her bladder was distended. Transabdominal ultrasonography indicated a retroverted uterus with a large uterine myoma which was pressing the bladder toward the abdominal wall (Figure). Bladder catheterization yielded 800 mL of clear urine. Neurologic examination was normal. No evidence of decreased sensation of the perineum or a decrease in levator muscle tone was found. Speculum examination showed that the cervix could not be visualized secondary to the anterior deflection. On bimanual examination, the uterus was the size of 12 weeks’ gestation, and a large uterine myoma was located in the posterior wall. Transvaginal ultrasound revealed a posterior fibroid mass 5.7 × 4.3 cm in size. The patient underwent a laparoscopic-assisted vaginal hysterectomy for symptomatic uterine myoma. On postoperative day 1, she was able to void spontaneously. While in the hospital, her voids ranged from 250 to 500 mL, with a post-void residual volume of less than 50 mL as checked after the first three voids. The patient no longer required special maneuvers to void. At the 4-week follow-up, the patient had no difficulty in initiating voiding or emptying her bladder. Obstructive urinary retention is an uncommon event in women of reproductive age without previous surgery. An impacted pelvic mass has also been described as a rare cause of urinary retention [2]. This problem can also be seen in pregnancy with an incarcerated uterus [3]. Trauma to the pelvis or perineum may cause either a hematoma or edema [4]. FEMALE ACUTE URINARY RETENTION CAUSED BY ANTERIOR DEFLECTION OF THE CERVIX WHICH WAS AUGMENTED BY AN UTERINE MYOMA

Metastatic adenocarcinoma of left supraclavicular fossa from occult primary ovarian cancer

Most of the metastatic cervical lymphadenopathy results from the upper aerodigestive tract [1]. Asymptomatic primary ovarian cancer in the presence of metastatic left supraclavicular lymph nodes is rare [2]. Whether to identify the primary tumor or to manage Stage IV ovarian cancer represents a clinical dilemma. We report a rare case of metastatic adenocarcinoma of the left supraclavicular fossa resulting from occult primary ovarian cancer. A healthy 53-year-old menopausal woman, parity 2002, presented with a growing lump as large as 8 6 3 cm in her left supraclavicular fossa; she had had the mass for 3 months, which on biopsy was diagnosed as a metastatic papillary tumor (Fig. 1A). She underwent panendoscopy (nasolaryngoscopy, bronchoscopy, gastroenteroscopy) and a series of imaging studies for primary malignancy, which demonstrated only lymphadenopathy in the left axillary region to the supraclavicular region (Fig. 2A). Finally, abdominal computed tomography showed a right pelvic mass measuring 13.5 7.4 10.5 cm with a cystic component and enlarged lymph nodes from the para-aortic to paracaval space. The patient had a gynecological oncology consultation and underwent exploratory laparotomy. The histopathology confirmed papillary serous cystoadenocarcinoma of both ovaries, coexisting with omentum cake and enlarged pelvic lymph nodes. The patient underwent a debulking operation with a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node dissection. However, because of unresectable status of multiple tumor metastases to the para-aortic, axillary, and supraclavicular lymph nodes, the

Successful treatment with recombinant blood factor VIIa in severe postpartum hemorrhage-induced disseminated intravascular coagulation.

Obstetric hemorrhage is the leading cause of maternal morbidity and mortality worldwide. Uterine atony leading to postpartum hemorrhage (PPH) is the most common type seen [1]. Other factors include genital tract lacerations, retained placenta, uterine inversion, and acquired or inherited coagulopathy. The World Health Organization defines PPH as a blood loss in excess of 500 mL after delivery; the common sites for blood loss include the uterus, cervix, vagina, and perineum [2]. Massive PPH (> 1 L) accounts for > 10% of all maternal deaths and can lead to permanent morbidity [3]. Therapeutic management strategies include uterine compression with massage or manual compression, compression sutures (B-Lynch procedure), increasing intrauterine pressure with balloon catheters or gauze packing, and/or uterotonic agents or intravenous hemostatic agents such as tranexamic acid (Transamin) and recombinant activated blood factor VIIa (rfVIIa) [4]. We describe a case of refractory massive PPH. The bleeding persisted even though vaginal packing and uterine artery embolization were administered. Disseminated intravascular coagulation (DIC) then developed, which we successfully corrected with two injections of rfVIIa. Interventions with rfVIIa in cases of PPH have been reported in the past decade. The first report of the use of rfVIIa in an obstetric patient with DIC following PPH was by Plaat [5] in

Prenatal diagnosis of a de novo 9p terminal chromosomal deletion in a fetus with major congenital anomalies

OBJECTIVE We describe a prenatal ultrasonography diagnosis of omphalocele and symbrachydactyly in a fetus and review the literature on prenatal diagnosis of 9p terminal chromosomal deletions. CASE REPORT A 31-year-old woman (gravida 3, para 1) was referred for genetic counseling because a fetal omphalocele had been detected. Prenatal ultrasonography at 17+ weeks of gestational age revealed a singleton female fetus with biometry equivalent to 18 weeks with an omphalocele. In addition, symbrachydactyly was also noted in the right arm; the wrist bones as well as the metacarpals were missing. A chromosomal study was arranged for a congenital anomaly involving omphalocele. We obtained Giemsa-banded chromosomes from fetal tissue cells, and an abnormal male karyotype with a terminal deletion of the short arm of chromosome 9 at band 9p13 was noted. After delivery, the fetus showed omphalocele, symbrachydactyly, trigonocephaly, sex reversal, a long philtrum, low-set ears, telecanthus, and a frontal prominence. CONCLUSION Prenatal diagnosis of abnormal ultrasound findings with omphalocele and symbrachydactyly should include the differential diagnosis of a chromosome 9p deletion.

Myocardial infarction and ischemic hepatitis complicated by postpartum hemorrhage

OBJECTIVE To present a rare case of life-threatening postpartum hemorrhage due to uterine atony complicated by acute myocardial infarction and ischemic hepatitis. CASE REPORT A 37-year-old parturient, gravida 1 para 0, presented with symptoms and signs of shock due to postpartum hemorrhage after delivery. Ischemic hepatitis, pulmonary edema, and adult respiratory distress syndrome developed the following morning. On the 7(th) postpartum day, she developed chest pain and was subsequently diagnosed with acute inferior myocardial infarction based on serial changes on the electrocardiogram (ECG) and myocardial enzymes. The clinical condition improved after a series of resuscitative efforts and percutaneous transluminal coronary angioplasty. CONCLUSION The presented case demonstrated that when hypovolemic shock develops with complications of pulmonary edema or ischemic hepatitis, the possibility of cardiovascular disease should be immediately investigated and preventive measures initiated.

Partial Trisomy 3p and Monosomy 7p Associated with Tetralogy of Fallot and Infantile Seizure

A 7-month-old female infant was referred because of hypothyroidism, seizure, respiratory distress syndrome, and tetralogy of Fallot (TOF) with hypoxic spell. Her father and 24-year-old mother were healthy and nonconsanguineous. There was no family history of congenital malformations. The mother denied any exposure to alcohol, teratogenic agents or infectious diseases during this pregnancy. She received regular prenatal examinations at a local clinic. The infant was born prematurely at 35 weeks of gestation. However, bradycardia, restlessness, cyanosis, gasping respiration, upgaze, and episodes of seizure developed soon after delivery. The infant’s external appearance was grossly normal, and the extremities were freely movable. The body weight was less than third percentile with growth restriction. Serial studies were arranged. Echocardiography revealed an atrial septal defect, a large ventricular septal defect, right ventricular hypertrophy, and severe pulmonary stenosis that were consistent with TOF. Brain sonography revealed moderate dilatation of lateral and third ventricles, in favor of the diagnosis of benign extracerebral fluid collection. Conventional cytogenetic studies performed on the

Dandy–Walker syndrome with duplex kidney abnormalities in trisomy 18 – A rare case report

OBJECTIVE Trisomy 18 is one of the major numerical chromosomal disorders. The incidence of trisomy 18 is approximately one in 6000 live births. Dandy-Walker malformation (DWM) is the most common congenital malformation of the cerebellum, with an incidence of about one in 5000 live births. The incidence of trisomy 18 associated with DWM is rare and long-term survival rate is very low. CASE REPORT A case involving a 39-year-old pregnant female with a case of trisomy 18 associated with DWM. CONCLUSION The incidence of trisomy 18 associated with DWM is rare, and our report presents an unusual case that supplements our knowledge of this condition. We report a case involving a 39-year-old pregnant female with a case of trisomy 18 associated with Dandy-Walker malformation (DWM). Fetal ultrasonography showed hypoplasia of the cerebellar vermis and dilatation of the fourth ventricle and was characterized by an enlarged posterior fossa. Fetal magnetic resonance imaging showed inferior vermian hypoplasia and a large posterior fossa cyst communicating with the fourth ventricle causing high insertion of the torcular herophili, which was compatible with DWM. Furthermore, the karyotyping report revealed trisomy 18. The incidence of trisomy 18 associated with DWM is rare, and our report presents an unusual case that supplements our knowledge of this condition.

Manual compression management for internal bleeding of Cul-de-Sac ectopic pregnancy

Abdominal ectopic pregnancy is rare among all ectopic pregnancies and only few cases were treated with laparoscopic surgery. The most challenging management is adequate hemostasis after the removal of gestational material. We present a case of abdominal ectopic pregnancy with massive hemoperitoneum who was treated with laparoscopy and manual hemostasis during the surgery. After the removal of gestational material, persistent bleeding from the rough surface of rectal serosa was observed. Thermal coagulation was dilemmatic due to proximity to the rectum. Then, we used manual compression with one index finger in the rectum combined with gauze compression by laparoscopic instrument. The hemostasis was achieved successfully.