P Reif

Rupture of endometriotic ovarian cyst causes acute hemoperitoneum in twin pregnancy

OBJECTIVE To present a case of an acute hemoperitoneum caused by a ruptured ovarian cyst in a late twin pregnancy. DESIGN Case report study. SETTING Department of Obstetrics and Gynecology, Medical University of Graz, Austria. PATIENT(S) A woman with a history of surgery for endometriosis and currently pregnant with dichorionic twins after IVF presented with acute abdominal pain. INTERVENTION(S) Serial ultrasound assessment revealed a massive hemoperitoneum that was caused by a ruptured endometriotic ovarian cyst. Emergency laparotomy was performed. MAIN OUTCOME MEASURE(S) Hemostasis. RESULT(S) Laparotomy led to operative hemostasis and preterm cesarean section of healthy twins at 27 weeks of gestation. CONCLUSION(S) Endometriosis occurs in about 10% of women of reproductive age and carries an infertility rate of up to 50%. Severe endometriosis used to be a rare event in patients with spontaneously conceived pregnancies. However, during the last decade, the increased use of assisted reproductive technologies has led to higher fertility rates in patients with endometriosis and to a higher incidence of multiple gestations. Therefore, the number of pregnant women with endometriosis and associated complications may rise.

Validation of a point-of-care (POC) lactate testing device for fetal scalp blood sampling during labor: clinical considerations, practicalities and realities.

Abstract Background: Although fetal blood sampling for pH is well established the use of lactate has not been widely adopted. This study validated the performance and utility of a handheld point-of-care (POC) lactate device in comparison with the lactate and pH values obtained by the ABL 800 blood gas analyzer. Methods: The clinical performance and influences on accuracy and decision-making criteria were assessed with freshly taken fetal blood scalp samples (n=57) and umbilical cord samples (n=310). Bland-Altman plot was used for data plotting and analyzing the agreement between the two measurement devices and correlation coefficients (R2) were determined using Passing‐Bablok regression analysis. Results: Sample processing errors were much lower in the testing device (22.8% vs. 0.5%). Following a preclinical assessment and calibration offset alignment (0.5 mmol/L) the test POC device showed good correlation with the reference method for lactate FBS (R2=0.977, p<0.0001, 95% CI 0.9 59–0.988), arterial cord blood (R2=0.976, p<0.0001, 95% CI 0.967–0.983) and venous cord blood (R2=0.977, p<0.0001, 95% CI 0.968–0.984). Conclusions: A POC device which allows for a calibration adjustment to be made following preclinical testing can provide results that will correlate closely to an incumbent lactate method such as a blood gas analyzer. The use of a POC lactate device can address the impracticality and reality of pH sample collection and testing failures experienced in day to day clinical practice. For the StatStrip Lactate meter we suggest using a lactate cut-off of 5.1 mmol/L for predicting fetal acidosis (pH<7.20).

Management of Bartholin's cyst and abscess using the Word catheter: implementation, recurrence rates and costs

OBJECTIVE Bartholins cysts and abscesses occur in about 2% of women. None of the surgical or conservative treatment approaches have been proven to be superior. The Word catheter is an outpatient treatment option, but little is known about aspects of implementing this therapy in an office setting. The present studys focus is on recurrence rates and organizational requirements of implementing outpatient treatment of Bartholins cyst and abscess and compares costs of Word catheter treatment and marsupialization. STUDY DESIGN Between March 2013 and May 2014 30 women were included in the study. We measured time consumed for treatment and follow-up and analyzed costs using the Word catheter and marsupialization under general anesthesia. We also assessed the ease of use of the Word catheter for application and removal using a standardized visual analog scale (VAS 1-10). RESULTS Word catheter treatment was successful in 26/30 cases (87%). Balloon loss before the end of the 4-week treatment period occurred in 11/26 cases with a mean residence time of 19.1 (±10.0) days. None of the patients with early catheter loss developed recurrent cyst or abscess. Recurrence occurred in 1/26 cases (3.8%). Difficulty-score of application was 2 [1-10] and of removal 1 [1], respectively. Costs were € 216 for the treatment in the clinic as compared with € 1584/€ 1282 for surgical marsupialization with a one-night stay or daycare clinic, respectively. CONCLUSIONS The present study indicates that the Word catheter is an easy to handle, low cost outpatient procedure with acceptable short-term recurrence rates. Treatment costs are seven times lower than for marsupialization.

Quality of life and sexual activity during treatment of Bartholin's cyst or abscess with a Word catheter

OBJECTIVES Cysts and abscesses of the Bartholin glands are a common occurrence in gynecologic or general practice. Little is known about restrictions in patients daily life and sexual activity during treatment of Bartholins cysts in general and especially with the Word catheter. This study is to assess the Quality of Life and Sexual Activity during treatment of Bartholin cysts and abscesses with the Word-catheter. STUDY DESIGN Between March 2013 and May 2014 30 women were included in the study. Pain before treatment and during catheter insertion and removal was assed using a standardized VAS scale. Health-related quality of life was assessed with the Short-Form-12-Health-Survey. Fallowfields Sexual Activity Questionnaire was administered to investigate sexual limitations. During treatment patient self-reported to a pain-diary (VAS 0-10). RESULTS Pain levels decreased from a 3 [0-10] on day 1 to 0 [0-6] on day 6 with the median staying at 0 for the remaining treatment period. Discomfort and pain during sexual activity decreased significantly from initial presentation to end of treatment. The mental component summary score of the SF 12 increased significantly from 46.94±10.23 before treatment to 50.58±7.16 after treatment (p=0.016); the physical component summary score did not change significantly. CONCLUSIONS The Word catheter is well tolerated for the treatment of Bartholins cysts and abscesses with few and no serious side effects and little impingement of sexual health. A more relevant informed consent ahead of treatment, specifically with regard to pain in the first few days after catheter placement, might further increase acceptance of the catheter and adjust patient expectations.

Short-term neonatal outcome in diabetic versus non-diabetic pregnancies complicated by non-reassuring foetal heart rate tracings

Abstract Objective: Analysis of the impact of non-reassuring foetal heart rate patterns (FHR) and suspected foetal distress during active labour on the neonatal outcome in diabetic compared to non-diabetic mothers. Methods: Retrospective case–control study comparing the short-term neonatal outcome including Apgar score at 5 min, and arterial/venous umbilical cord blood pH of 57 deliveries of women with different types of diabetes and 114 healthy controls. Patients were selected out of all deliveries with suspected foetal distress during active labour and performed foetal scalp pH samplings (n = 590) at the Medical University of Graz, Austria, during 2008–2009. Results: Arterial pH was significantly lower in the diabetic group (7.215 versus 7.250, p = 0.007). Apgar scores ( > 8) at 5 min were similar in both groups (96.5% versus 95.6%, p = 0.566). The percentage of cases with foetal scalp blood pH <7.25 was higher in the diabetes group, but did not reach statistical significance (14.1% versus 7.1%, p = 0.166). Conclusions: Newborns of women with gestational and type 1 diabetes and non-reassuring FHR tracing have significantly lower arterial cord blood pH values without consequences on neonatal postpartum adaptation. Special attention to pathological changes in FHR patterns and to the more rapid decline in foetal pH during periods of foetal distress may be warranted in women with gestational and pre-conceptional diabetes during active labour. More frequent foetal scalp pH testing to rule out clinically relevant foetal acidosis needs to be discussed.

Efficacy of misoprostol in relation to uterine position in the treatment of early pregnancy failure

To evaluate the efficacy of misoprostol in the treatment of missed or incomplete abortion in relation to uterine position.

Practicability of fetal scalp blood sampling during labor using microtubes and a point-of-care (POC) lactate testing device: difficulty assessment, sampling time and failure rates.

*Corresponding author: Philipp Reif, MD, Department of Obstetrics and Gynecology, Medical University of Graz, Auenbruggerplatz 14, 8036 Graz, Austria, Phone: +43 316 385 80053, Mobile: +43 699 11883089, Fax: +43 316 681835, E-mail: philipp.reif@medunigraz.at Daniela Ulrich, Ioana Lakovschek, Carmen Tappauf, Uwe Lang and Wolfgang Schöll: Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria Letter to the Editor

Metastasis of an undifferentiated fetal soft tissue sarcoma to the maternal compartment of the placenta: maternal aspects, pathology findings and review of the literature on fetal malignancies with placenta metastases

Sir: Cancers in pregnancy affect approximately 0.1% of all pregnant women, and the large majority are of maternal origin. While more than 50 cases of maternal cancers with metastases to the placenta and 14 cases of transplacental transmission to the fetus have been reported, primary fetal malignancies with placental involvement are extremely rare. We report the first case of an undifferentiated fetal soft tissue sarcoma involving the maternal compartment of the placenta with metastases to the chorionic villi and the intervillous space, and review all documented cases of fetal malignancies with metastases to the placenta or to the mother.

Fetal head entrapment through a spontaneous chorionic septostomy in a first trimester dichorionic diamniotic twin pregnancy: a case report.

CASE REPORT A 41-year-old, gravida 4, para 2, with dichorionic diamniotic (DCDA) twins was referred after spontaneous septostomy of the intertwin chorionic membrane and increased nuchal translucency and unilateral talipes in one twin fetus at 12 +0weeks gestation. The patient had a history of surgery for uterine fibroids followed by two spontaneous deliveries and an early fetal loss at 8weeks gestation. Conception in the present pregnancy was spontaneous. The referring physician described the head of the left-sided twin (twin B) as herniating through the chorionic membranes into the sac of the right-sided twin (twin A) (Figure 1). The nuchal translucency (NT) was 5mm in that twin with unilateral talipes at 10+ 2weeks gestation as well as at 12+ 0weeks gestation. On the basis of the later scan, the risk for trisomy 21 for the prolapsed twin and the unaffected one was 1:2 and 1:1109 and for trisomy 13/18, 1:3 and 1:1347, respectively; ductus venosus Doppler, tricuspid flow, and biochemistry were normal in both twins. Umbilical cords were not entangled or showed signs of compression and both placentas were described as insuspect in posterior position. Amniocentesis was offered but was declined by the patient. Sonographic examination at our Maternal Fetal Medicine Unit at 12 + 4weeks gestation showed a Lambda-sign, the thickness of the dividing membrane was 2.1mm. A defect of 10mm in the chorionic membrane was clearly visible, with the amniotic membrane of twin B protruding into the contralateral sac. The head of twin B was stuck in this sac. The fetal head was entrapped through the chorionic defect, but neck movements were still possible to a certain extent. Because of the striking image and the potential impact of a narrowing gap, we considered fetoscopic surgery with the purpose to widen the gap. However, further ultrasound examinations at a fortnightly interval showed enlargement of the membrane defect. At 21 + 0weeks gestation, the gap measured 21mm and the fetal head was no longer stuck. Varying fetal positions were found including prolapsed fetal head as well as prolapsed lower limbs and rump. Fetal growth and umbilical artery Doppler measurements were adequate in both twins. Except for unilateral talipes in twin B, no abnormalities were detected. The NT thickness decreased from 5mm at 12 + 0weeks gestation to 3.4mm at 12 + 4weeks gestation and was inconspicuous later on. At 31 + 1weeks the woman presented with spontaneous preterm rupture of membranes. Cesarean section was performed and fetuses weighting 1654 g (Twin A, female, cephalic position) and 1622 g (Twin B, male, breech position) were delivered in good condition. At cesarean section, the amniotic sac of twin B was found intact with a sacculation through the defect in the dividing membrane. The size of the defect was described as comprising half of the size of the dividing membrane. Placental examination confirmed two fused DCDA placentas measuring 19 14 1.5 cm and 19 12 1.5 cm. Umbilical cord length was 12 cm with velamentous insertion for twin A and 18 cm with marginal insertion for twin B. There was no evidence of chorioamnionitis, villitis, or intervillositis. After a 3-year follow-up period, both twins show normal development. As there were no signs of chromosomal anomalies, karyotyping was not performed. The talipes required surgical repair. Although twin gestations account for only 1–2% of all pregnancies, about 10% of all perinatal deaths occur in this population. Monoamniotic twins carry the highest risks among twin gestationsmainly because of a lack of a dividingmembrane. We present a rare event of spontaneous first trimester spontaneous septostomy of the chorionic membranes in a DCDA twin pregnancy. Only two cases of true spontaneous septostomy of the chorionic membranes in DCDA twins have been reported. In one of these, both chorionic and amniotic

Rates and Routes of Hysterectomy for Benign Indications in Austria 2002 – 2014

INTRODUCTION Rates and routes of hysterectomy have implications for quality, costs and training. This study analyzed rates of benign hysterectomy and surgical approaches for benign hysterectomy in Austria from 2002 to 2014. MATERIAL AND METHODS This was a population-based retrospective observational study of coding data from all acute care hospitals (public and private) in Austria. Main outcome measures were numbers of women undergoing hysterectomy for benign indications in Austria per year and the route of hysterectomy for benign indications. RESULTS The number of benign hysterectomies performed per year declined from 10 675 in 2002 to 7747 in 2014, a decline of 27%. The use of vaginal hysterectomy was stable (53% and 47%, respectively). Use of laparoscopic techniques increased (5% in 2002, 32% in 2014) whereas use of abdominal hysterectomy decreased (41% and 20%, respectively). CONCLUSIONS Numbers of benign hysterectomies performed per year in Austria declined substantially between 2002 and 2014. Use of vaginal hysterectomy was stable at about 50%, whereas increased use of laparoscopic techniques was associated with lower rates of open hysterectomy.