Pei Shan Lim

Update on the management of ovarian torsion in children and adolescents

BackgroundOvarian torsion is commonly seen in young girls. Unfortunately it is often misdiagnosed because of its non-specific symptoms and lack of diagnostic modalities. This article focuses on the diagnostic challenge and also the changes in the management of ovarian torsion.Data sourcesWe reviewed original reports on the management of ovarian torsion in young girls published from 1984 till 2014. A literature search was conducted by electronic scanning of five electronic database: MEDLINE, EMBASE, SCI, SSCI and CINAHL. In addition, relevant papers and review articles were hand-searched. The search was limited to English language and human studies. The search was conducted by combining the textwords “ovarian torsion”, “adnexal torsion”, “adolescents” and “oophoropexy”.ResultsThere are no specific symptoms that can be identified as a pathognomonic feature of ovarian torsion. Ultrasound is a useful diagnostic tool, but it is not always reliable in absence of an enlarged ovary. Laparoscopic detorsion is recognized as the mainstay of treatment regardless the condition of the ovaries. Reports have shown favorable ovarian function after detorsion. The role of oopheropexy remains controversial.ConclusionsClinicians should be aware of ovarian torsion in girls presenting with abdominal pain. A timely management in this young population can help preserve their ovaries and fertility.

Spontaneous rupture of uterine varicose veins: A rare cause for obstetric shock

Spontaneous rupture of uterine surface varicose veins is rare but may result in serious complication of pregnancy, as it is associated with high perinatal and maternal mortality. We report a 24‐year‐old primigravida who presented with this rare condition mimicking placenta abruption, which was successfully managed. A review of reported cases was performed.

Comparison between Amnisure Placental Alpha Microglobulin-1 Rapid Immunoassay and Standard Diagnostic Methods for Detection of Rupture of Membranes

Objective. To determine the diagnostic accuracy of placental alpha microglobulin-1 assay and standard diagnostic methods for detecting rupture of membrane. Study Design. Prospective diagnostic study, between June 2011 to November 2011 at a tertiary centre. Initial evaluation included both the standard diagnostic methods for rupture of membranes and placental alpha microglobulin-1 immunoassay. The actual rupture of membranes was diagnosed on review of the medical records after delivery (absence of membrane or a positive pad chart). Main Outcome Measures. Placental alpha microglobulin-1 immunoassay and standard diagnostic methods for diagnosis of rupture of membrane. Results. A total of 211 patients were recruited. At initial presentation, 187 patients (88.6%) had ruptured membranes, while 24 patients (11.4%) had intact membranes. Placental alpha microglobulin-1 immunoassay confirmed rupture of membranes at initial presentation with a sensitivity of 95.7% (179 of 187), specificity of 100% (24 of 24), positive predictive value of 100% (179 of 179), and negative predictive value of 75.0% (24 of 32). By comparison, the conventional standard diagnostic methods had a sensitivity of 78.1% (146 of 187), specificity of 100% (24 of 24), positive predictive value of 100% (146 of 146), and negative predictive value of 36.9% (24 of 65) in diagnosing rupture of membrane. Conclusion. Placental alpha-microglobulin-1 immunoassay is a rapid and accurate method for confirming the diagnosis of rupture of membrane. It was superior to conventional standard diagnostic methods (pooling, nitrazine, and ferning), the nitrazine test alone or fern test alone.

Factors Associated with Placenta Praevia in Primigravidas and Its Pregnancy Outcome

Aim. To examine the factors associated with placenta praevia in primigravidas and also compare the pregnancy outcomes between primigravidas and nonprimigravidas. Method. A retrospective cohort study was conducted in women who underwent caesarean section for major placenta praevia in a tertiary university hospital from January 2007 till December 2013. Medical records were reviewed. Result. Among 243 with major placenta praevia, 56 (23.0%) were primigravidas and 187 (77.0%) were nonprimigravidas. Factors associated with placenta praevia in the primigravidas were history of assisted conception (P = 0.02) and history of endometriosis (P = 0.01). For maternal outcomes, the nonprimigravidas required earlier delivery than primigravidas (35.76 ± 2.54 weeks versus 36.52 ± 1.95 weeks, P = 0.03) and had greater blood loss (P = 0.04). A vast majority of the primigravidas had either posterior type II or type III placenta praevia. As for neonatal outcomes, the Apgar score at 1 minute was significantly lower for the nonprimigravidas (7.89 ± 1.72 versus 8.39 ± 1.288.39 ± 1.28, P = 0.02). Conclusion. This study highlighted that endometriosis and assisted conception were highly associated with placenta praevia in primigravida. Understanding the pregnancy outcomes of women with placenta praevia can assist clinicians in identifying patients who are at higher risk of mortality and morbidity. Identifying potential risk factors in primigravida may assist in counseling and management of such patients.

Utero-cutaneous fistula after caesarean section secondary to red degeneration of intramural fibroid

A 33 year-old woman had an emergency caesarean section for retained second twin which was complicated by utero-cutaneous fistula due to red degeneration of intramural fibroid. The utero-cutaneous communication was demonstrated by an examination under anaesthesia using dye test. She then underwent excision of the fistula tract and myomectomy. She recovered well following the surgery. This is the first case of utero-cutaneous fistula where the communication is between the endometrial cavity and skin lesion via a necrotic intramural fibroid following caesarean section. Fistulogram might fail to demonstrate the communication. In highly suspected case, other modalities of investigations could be utilised.

Heterotopic triplet pregnancy with bilateral tubal ectopic post-IVF-ICSI of two 12-cell embryos

A heterotopic pregnancy is the coexistence of intrauterine and extrauterine pregnancy. It can be as rare as 1:30,000 in spontaneous pregnancies but can be as high as 1:100 following artificial reproductive techniques (ART) [1]. Bilateral tubal ectopic pregnancy is another extremely rare clinical condition, with an estimated prevalence of 1:200,000 in spontaneous pregnancies [2]. It accounts for one in 750 to one in 1580 ectopic pregnancies [3]. Heterotopic triplets are even more uncommon, and cases with bilateral tubal ectopics and coexisting intrauterine pregnancy are limited, if not unheard of. To add to the rarity of these clinical conditions is when there is a heterotopic triplet pregnancy with bilateral tubal ectopics resulting from the transfer of only two embryos as is explained in the case of our patient. Our patient was a 37-year-old woman with unexplained secondary subfertility of 6 years (gravida 2, para 0 þ 1 miscarriage) with a confirmed intrauterine pregnancy after her first attempt of in vitro fertilization (IVF). She had controlled minimal ovarian stimulation for a total of 10 days. Four mature eggs were retrieved on Day 11, and intracytoplasmic sperm injection was performed on all the eggs. Only two embryos at the 12-cell stage were found suitable for transfer. The patient was prescribed with oral dydrogesterone 8 hourly for luteal support. The Day-10 posttransfer serum b hCG level confirmed a successful implantation, and she was scheduled for follow up. Unfortunately, she presented herself

Bowel endometriosis: a diagnostic and therapeutic challenge

Abstract Bowel endometriosis is the most common extragenital manifestation of endometriosis. Clinical suspicion is of utmost importance for achieving its diagnosis. Management of this condition is, however, always challenging to the gynaecologist. We report a case of bowel endometriosis in which the patient presented with dyschezia and haematochezia prior to her menses for the past 2 years. A 44-year-old para two woman presented with worsening dysmenorrhea and dyspareunia. She also experienced dyschezia and haematochezia prior to her menses for the past 2 years. An examination revealed a fixed retroverted uterus. A computed tomography scan showed focal bowel thickening. She underwent a colonoscopy examination and biopsy that revealed stromal endometriosis. She was subsequently treated with dienogest and became asymptomatic. Diagnosis and management of this debilitating illness was revisited and discussed.

Cesarean scar pregnancy: What can we offer?

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy where implantation of the gestational sac occurs at the previous scar with the surrounding myometrium [1]. The incidence reported by Seow et al [2] was extremely low (approximately 1 in 2000), which is consistent with the prevalence of 1:1800 reported by Jurkovic et al [3]. The precise mechanism is still not clear and poorly understood. Implantation of the conceptus into the myometrium through a microscopic tract or scar defect had been suggested [4]. Catastrophic and life-threatening complications such as uterine rupture and massive hemorrhage could occur in case of misdiagnosis. Therefore, prompt and early diagnosis is essential to facilitate early intervention. This is a case of CSP successfully treated with local injection of methotrexate (MTX) and hypertonic dextrose solution. Subsequent vaginal bleeding after the termination of CSP was effectively controlled by tranexamic acid followed by gonadotropin releasing hormone analog (GnRHa). This approach resulted in avoidance of surgical intervention. A 30-year-old gravida 3 para 2 woman in the 9th week of amenorrhea who had two previous cesarean sections (CSs), was referred for an incidental finding of CSP during her first antenatal visit. She was asymptomatic, and the result of her physical examination was unremarkable. An ultrasound scan noted a gestational sac embedded at the previous CS scar. The pregnancy was considered viable with a crown rump length of 25.8 mm. The uterine cavity was empty with no free fluid seen in the pouch of Douglas (Figs. 1e3). Her serum beta human chorionic globulin

Reviewing the role of progesterone therapy in endometriosis

Abstract Endometriosis is a benign, chronic inflammatory condition characterized by the presence and growth of endometrial implants outside the uterine cavity. The cause of endometriosis is multifactorial. It is due to the diversity of hypothesis and plausibility of hormonal alterations which could play a major role. Evidence has shown that progesterone resistance is a key factor for endometriosis sufferers. Medical therapy can avoid surgical intervention, which may lead to a reduced in ovarian reserve, and its effects of earlier menopause and reduced fecundity. Progesterone receptor isoform has provided new insight as the potential treatment. Progestin, anti-progestin and selective progesterone receptor modulators usage, which target these receptors, could avoid hypo-estrogenic side effects, which can be debilitating. Numerous types of these medications have been used on and off labeled to treat endometriosis with varying success. This review aims to consolidate series of clinical trials using progestins in endometriosis.

Comparison of 25-hydroxyvitamin D and metabolic parameters between women with and without polycystic ovarian syndrome

Abstract Background There is increasing evidence that supports the contribution of vitamin D deficiency in metabolic disturbances among women with polycystic ovarian syndrome (PCOS). The aim of this study was to compare 25-hydroxyvitamin D level and the prevalence of metabolic syndrome in the PCOS and normal women. Materials and methods A case-controlled study was conducted in a teaching hospital over a 6-month duration from June 2015 to January 2016. A total of 90 women, who consisted of 45 women with PCOS (study group) and 45 women without PCOS (control group), were recruited. Results The final analysis was of 80 women only and the prevalence of vitamin D deficiency (<20 ng/mL) was high between both groups, i.e. 93.7% but there was no significant difference (p = 0.874). Nevertheless, the prevalence of metabolic syndrome was significantly higher in the study group as compared to the control group (27.5% vs. 5.0%, p = 0.013). There was no statistically significant correlation between vitamin D level with clinical [age, weight, body mass index (BMI), waist and hip circumference, systolic and diastolic blood pressure (SBP and DPB, respectively)] and metabolic parameters (fasting glucose, triglycerides, cholesterol, high-density lipoprotein and low-density lipoprotein) among women with PCOS. However, height was positively correlated (r = 0.338, p = 0.033) and the contrary waist-hip ratio was negatively correlated with vitamin D level (r = −0.605, p = 0.048). Conclusion The prevalence of vitamin D deficiency was high in our study population. Nevertheless, the prevalence of metabolic syndrome was higher among women with PCOS as compared to women without PCOS.