Matthew J. Blitz

Management of Isolated Tubal Torsion in a Premenarchal Adolescent Female with Prior Oophoropexy: A Case Report and Review of the Literature

BACKGROUND Isolated tubal torsion in a premenarchal adolescent girl is a rare phenomenon. Preoperative diagnosis remains a challenge. CASE A 14-year-old premenarchal girl, with a history of bilateral ovarian torsion treated by laparoscopic detorsion and oophoropexy two years prior, presented to the emergency room with lower abdominal pain accompanied by nausea and vomiting. Pelvic ultrasound demonstrated an enlarged left adnexa. Diagnostic laparoscopy revealed an isolated left tubal torsion. Surgical evidence of previous bilateral plication of the utero-ovarian ligaments was confirmed. Untwisting of the left fallopian tube immediately restored the vascular supply. Subsequently, her symptoms resolved. SUMMARY AND CONCLUSION Clinicians should consider torsion of the fallopian tube in the differential diagnosis of lower abdominal pain in all female patients. Prompt laparoscopic intervention is essential. Oophoropexy, while usually efficacious, may not prevent recurrence.

Prenatal Diagnosis of Ectrodactyly in the First Trimester by Three-Dimensional Ultrasonography

Introduction Ectrodactyly, also known as split hand/foot malformation, is a rare developmental abnormality of the limbs that consists of absent central digits, a deep median cleft, and fusion of the remaining lateral digits, ultimately producing clawlike extremities. This case represents one of the earliest reported diagnoses of this anomaly to utilize three-dimensional (3D) ultrasonography. Case A nulliparous woman presented at 13 weeks of gestation for first-trimester aneuploidy screening. On two-dimensional (2D) imaging, she was noted to have a fetus with a shortened right upper limb and a malformed right hand with no clearly visualized digits. The anomaly was then further evaluated with both transabdominal and transvaginal 2D and 3D ultrasonography with postprocessing visualization, revealing absent central digits. Neither the patient nor her husband reported any personal or family history of skeletal or other structural malformations. Discussion Fetal limb abnormalities are being encountered at increasingly earlier gestational ages due to improvements in image quality and expanded use of ultrasound in the first trimester. Early identification of fetal limb malformations without a definitive diagnosis or a clear pattern of inheritance can present a challenging clinical scenario. Patients may opt for earlier termination of pregnancy rather than wait for additional information to guide decision-making.

Uterine fibroids at routine second-trimester ultrasound survey and risk of sonographic short cervix.

Abstract Objective: To determine whether women with sonographically identified uterine fibroids are at higher risk for a short cervix. Methods: This retrospective cohort study evaluated all women with singleton gestations who had a routine second-trimester ultrasound at 17–23 weeks gestational age from 2010 to 2013. When fibroids were noted, their presence, number, location and size were recorded. Exclusion criteria included a history of cervical conization or loop electrosurgical excision procedure (LEEP), uterine anomalies, maternal age greater than 40 years, and a previously placed cerclage. The primary variable of interest was short cervix (<25 mm). Secondary variables of interest included gestational age at delivery, mode of delivery, indication for cesarean, malpresentation, birth weight, and Apgar scores. A multivariable logistic regression analysis was performed. Results: Fibroids were identified in 522/10 314 patients (5.1%). In the final multivariable logistic regression model, short cervix was increased in women with fibroids (OR 2.29, 95% CI: 1.40, 3.74). The number of fibroids did not affect the frequency of short cervix. Fibroids were significantly associated with preterm delivery (<37 weeks), primary cesarean, breech presentation, lower birth weight infants, and lower Apgar scores. Conclusions: Women with uterine fibroids may be at higher risk for a short cervix. Fibroids are also associated with several adverse obstetric and neonatal outcomes.

Severe Hyponatremia Associated with Use of Black Cohosh during Prolonged Labor and Unsuccessful Home Birth

Introduction There has been an increase in the use of herbal supplements during pregnancy, which are frequently of unproven efficacy and safety. We present a case of severe hyponatremia and altered mental status associated with the use of black cohosh during prolonged labor. Case A 39-year-old primigravida at 385/7 weeks of gestational age presented to the emergency department after she became disoriented and lethargic while laboring at home with a midwife. She had consumed several doses of black cohosh to induce and augment labor. On presentation, she was nonverbal and unable to follow commands. Her serum sodium was 114 mmol/L (range, 132–145 mmol/L), serum osmolality was 253 mOsm/kg (range, 275–300 mOsm/kg), urine osmolality was 190 mOsm/kg (range, 300–900 mOsm/kg), and urine sodium was <10 mmol/L. The patient soon became uncooperative and combative and a cesarean section was performed. Postoperatively, she was transferred to the intensive care unit for monitoring and correction of her sodium. Her mental status returned to baseline and she was subsequently discharged home without further complication. Discussion Clinically significant hyponatremia associated with pregnancy is rare. Further investigation is needed to evaluate the safety and efficacy of black cohosh and other commonly used herbal supplements during pregnancy and labor.

Torsion of fallopian tube remnant associated with noncommunicating rudimentary horn in adolescent girl with unicornuate uterus.

BACKGROUND The prevalence of müllerian anomalies may be as high as 7% in the general population, yet there is scant published literature on adnexal torsion occurring in these patients. CASE A 14-year-old female presented with right lower quadrant pain. Pelvic ultrasonography demonstrated a 2-cm simple right adnexal cyst. Diagnostic laparoscopy revealed a unicornuate uterus with a normal left uterine horn and fallopian tube but atretic and cordlike müllerian structures on the right side. Torsion of the right tubal remnant and two paratubal cysts were noted and the structures were then excised. SUMMARY AND CONCLUSION Agenesis, hypoplasia, or maldevelopment of müllerian structures may predispose patients to an increased risk of adnexal torsion secondary to looser ligamentous attachments and consequent lack of fixation to the pelvic sidewall.

Ultrasound and histological measurements of dividing membrane thickness in twin gestations

To determine how prenatal ultrasound measurements of dividing membrane thickness correlate with postnatal histological measurements and chorionicity in twin gestations.

Ultrasonic Assessment of Cervical Heterogeneity for Prediction of Spontaneous Preterm Birth: A Feasibility Study

Abstract Background In a normal pregnancy, cervical collagen fibers remain organized in predictable patterns throughout most of the gestation. Cervical remodeling reflects a rearrangement of collagen fibers in which they become increasingly disordered and contribute to the pathogenesis of spontaneous preterm birth. Quantitative ultrasound analysis of cervical tissue echotexture may have the capacity to identify microstructural changes before the onset of cervical shortening. Objective The primary objective of this study was to examine the utility of a novel quantitative sonographic marker, the cervical heterogeneity index (HI), which reflects the relative organization of cervical collagen fibers. Also, we aimed to determine an optimal HI cut‐point to predict spontaneous preterm birth. Study Design This retrospective cohort study employed a novel image‐processing technique on transvaginal ultrasound images of the cervix in gestations between 14 and 28 completed weeks. The transvaginal sonography images were analyzed in MATLAB (MathWorks, Natick, MA) using a custom image‐processing technique that assessed the relative heterogeneity of the cervical tissue. Results A total of 151 subjects were included in the study. The mean HI in subjects who delivered preterm and at term was 8.28 ± 3.73 and 12.35 ± 5.80, respectively (p < 0.0001). Thus, decreased tissue heterogeneity was associated with preterm birth, and increased tissue heterogeneity was associated with delivery at term. In our study population, preterm birth was associated with a short cervix (<2.5 cm), history of preterm birth and lower HI, and our findings indicate that HI may improve prediction of preterm birth. Conclusion Quantitative ultrasound measurement of the cervical HI is a promising, noninvasive tool for early prediction of spontaneous preterm birth.

Quantitative Ultrasound Analysis of Proximal and Distal Cervical Tissue Echogenicity in Premature Cervical Remodeling: Proximal and Distal Cervical Tissue Echogenicity

To determine whether a novel, noninvasive quantitative ultrasound (US) technique can detect differences in proximal and distal cervical tissue echogenicity in women with and without a shortened cervical length (CL).

Maternal Body Mass Index and Amniotic Fluid Index in Late Gestation

To determine the effect, if any, of an increasing maternal body mass index (BMI) on sonographically diagnosed oligohydramnios in late gestation and how it subsequently affects obstetric and neonatal outcomes.

Prenatal sonographic findings in a case of Wolman's disease

No published case of Wolmans disease has described the prenatal sonographic findings. We present a case in which a third‐trimester sonographic examination demonstrated fetal hepatomegaly and bilateral adrenal echogenicity suggestive of diffuse calcification. Wolmans disease, also known as lysosomal acid lipase (LIPA) deficiency, is a rare autosomal‐recessive disorder characterized by complete absence of the LIPA enzyme. The diagnosis of Wolmans disease was made postnatally by biochemical testing, which indicated absence of LIPA enzyme activity and gene sequencing, which confirmed homozygosity for the G66V mutation within the LIPA gene.