Soon-Cen Huang

Ultrasonographic Evaluation of the Change in Uterine Fibroids Induced by Treatment with a Gnrh Analog

OBJECTIVE To investigate the change in volume of uterine fibroids after GnRH analog (GnRHa) treatment. MATERIALS AND METHODS Twenty-five patients who had a uterine leiomyoma were included in this study. Four of them were lost to follow-up during the study, and a myomectomy was performed on the remaining subjects. All of these patients received two doses, 4 weeks apart, each of 3.75 mg leuprorelin acetate subcutaneously (Leuplin depot, a GnRHa) before the operation. The vascularization index (VI), flow index (FI), vascularization-flow index (VFI), pulsative index (PI), resistance index (RI), vascular patterns (histogram), blood flows, and sizes (volume and largest diameter) of each fibroid were measured with power Doppler by the same technician every month before the operation. In addition, the total blood loss and time required for each operation were also recorded. RESULTS Results of this study showed that the volume of the uterus and the fibroids, but not the vascularity, including VI, FI, VFI, PI and RI, decreased significantly after two doses of GnRHa treatment. In addition, blood loss during the operation decreased significantly compared to an untreated group. CONCLUSION We found that the volumes of the uterus and fibroids decreased significantly after treatment with two consecutive doses (given a month apart) of GnRHa. The 3D color Doppler including a histogram and blood flow parameters is another useful tool for fibroid evaluation.

Third- and fourth-degree perineal laceration in vaginal delivery

The perineal body, located between the vagina and the rectum, is formed predominantly by the bulbocavernosus and transverse perineal muscles. The puborectalis muscle and the external anal sphincter contribute additional muscle fibers. The anal sphincter complex lies inferior to the perineal body. The external anal sphincter is composed of skeletal muscle. The internal anal sphincter, which overlaps and lies superior to the external anal sphincter, is composed of smooth muscle and is continuous with the smooth muscle of the colon. The anal sphincter complex extends for a distance of 3e4 cm [6]. The internal anal sphincter provides most of the resting anal tone that is essential for maintaining continence. Laceration of this sphincter is associated with anal incontinence [4]. Interestingly, repair of the internal anal sphincter is not described in standard obstetric textbooks [7,8].

Fetal Congenital Lobar Emphysema

OBJECTIVE To report a rare fetal congenital lung anomaly characterized by over inflation of a pulmonary lobe. CASE REPORT A 28-year-old systemic lupus erythematous mother, gravida 1 para 0, who had normal prenatal care in our department, was admitted for labor pain and an abnormal fetal heart location was noted incidentally during labor. The baby showed rib retraction in room air but no obvious cyanotic change after delivery. Both the fetus chest X-ray and ultrasound showed a hyperechogenic tumor in the left thoracic cavity with a right-side-shifted heart and trachea. Computed tomography showed a hypodense and multiseptal tumor in the left thoracic cavity with right-sided shift of the heart and trachea. It was a soft, solid tumor in the parenchyma of the left lung and the histopathology confirmed it to be benign congenital lobar emphysema. CONCLUSION The favorable outcome in both asymptomatic and mildly symptomatic children suggests that a nonsurgical approach should be considered for these patients.

Postpartum hemorrhage of genital tract origin.

Postpartum hemorrhage is a highly serious risk for obstetric patients. It remains the main cause of maternal morbidity and mortality. It can be treated medically or conservatively without any sequelae, or it requires surgical intervention to repair the wound and artery ligation or transarterial embolization of the hypogastric, ovarian, or uterine vessels. We report three cases of postpartum hemorrhage of genital origin, resulting in hypotension and impending hypovolemic shock, in which the total blood loss was more than 1,500 mL.

Ruptured Tubo-Ovarian Abscess in a Postmenopausal Woman Presenting with Septic Shock: a Case Report and Literature Review

OBJECTIVE To report a case of a ruptured tubo-ovarian abscess which induced septic shock in a postmenopausal woman. CASE REPORT A 53-year-old postmenopausal woman was transferred to our emergency department for drowsiness, hypotension, and lower abdominal discomfort. Transabdominal sonography and computed tomography showed a large pelvic tumor over the left adnexa with some ascites. The uterus and other adnexa were unremarkable. Laboratory data, including blood count and electrolytes, showed leukocytosis and azotemia. Under suspicion of a ruptured adnexal tumor, laparotomy was performed and showed a large ruptured tubo-ovarian tumor arising from the left adnexa with intra-abdominal pus formation. Subtotal hysterectomy and bilateral salpingo-oophorectomy led to massive bleeding during manipulation of the left adnexa because of the necrotic change in the left infundibulopelvic vessels. Deep vein thrombosis and wound disruption occurred after the operation, but, fortunately, she recovered 1 month later. CONCLUSION Tubo-ovarian abscesses in postmenopausal women are uncommon but should be kept in mind with a pelvic tumor accompanied by septic shock, as this may cause a terrible outcome and other sequelae.

Neonatal coagulopathy presents as unusual and severe subgaleal hematomas after vacuum delivery.

Neonatal subgaleal hematomas (SGHs) are infrequent but may be underdiagnosed collections of blood beneath the galea, often caused by vacuum delivery. With massive bleeding into the subgaleal space, exsanguination and hypovolemic shock have caused death in 20–60% of newborn infants [1]. SGHs are mostly caused by vacuum delivery, and sometimes by neonatal coagulopathy. We report a case of a newborn who suffered from severe SGHs and anemia on the third day after delivery. A 26-year-old, gravida 1, para 0, mother, who had regular prenatal care at our hospital with no abnormal laboratory data or abnormal sonographic findings, was admitted to our delivery room at 38 weeks’ gestation for labor. The first and second stages of labor took about 15 hours and 6 hours, respectively. Vacuum extraction was used because of maternal exhaustion and prolonged second stage. Third-degree perineal laceration was found after delivery. The male baby was active and irritable after delivery, with Apgar scores of 9 and 10 at 1 and 5 minutes, respectively. A small caput succedaneum occurred as usual, on the posterior fontanel. Unfortunately, the caput succedaneum seemed to progress until a big cephalohematoma was noted on the third day of delivery. It crossed the midline (sagittal suture) and covered the whole occipital area down towards the posterior neck, even though we packed it with an elastic cap. It continued to grow toward the anterior neck region and then the cheek. Patches of ecchymosis were noted over the eyelids (Figure), anterior neck, and ears. Because of this unusual appearance,

A borderline ovarian Brenner tumor mimicks uterine fibroids

Brenner tumors are uncommon tumors that are a part of the surface epithelialestromal tumor group of ovarian neoplasms. Most of these tumors are benign. However, they can be malignant. They are most frequently detected as incidental findings on pelvic examination or at laparotomy. Besides, they can occur in other locations very rarely, including the testes. We report on this rare, gynecological, borderline adnexal tumor because it mimicks the common, benign uterine fibroids we see in our daily practice. A 47-year-old woman had a 3-year history of profuse menstrual bleeding. The gynecological ultrasound showed an enlarged uterus with a right-wall tumor mass measuring about 50 mm in size. We suggested conservative treatment and regular ultrasound follow-up. Unfortunately, the tumor was accompanied by several microcalcifications and grew to 80 mm within 6 months (Fig. 1), when surgical intervention was indicated. During the operation, the uterus appeared to be in normal size, but an enlarged right ovarian solid tumor, about 8 cm in size, was adhered to the uterus and the peritoneum. This solid tumor’s surface was smooth, and the content was yellowish in color (Fig. 2). Unfortunately, the frozen section showed malignant cells of fibrous composition in the tumor, and the metastatic tumor was first impressed. Complete staging surgery, including a total hysterectomy, a bilateral salpingo-oophorectomy, an infracolic omentectomy; a pelvic and para-aortic lymph node sampling; and an appendectomy were done. The gross tumor (about 8 cm in size) was in the right ovary, with the outer surface lobulated, intact, and without adhesions. The sectioned surface of the main tumor contained 100% solid components that were yellow-white in color with a firm consistency. The contralateral ovary was mildly enlarged with focal, whitish nodule formation (18 mm). The other specimens were unremarkable. The microscopic findings indicated a right ovarian tumor exhibiting irregular epithelioid tumor nests infiltrating a dense

Recurrent Placental Microcalcifications in the Second Trimester

Placental problems are uncommon during pregnancy. Benign pathologic findings of the placenta include placenta previa or abruption, velamentous cord insertion, succenturiate lobe, circumvallate placenta, battledore placenta, placentomegaly, and chorioangioma. We present the case of a mother who experienced recurrent placental microcalcifications in the early second trimester, with associated intrauterine growth retardation (IUGR). A 27-year-old woman, gravida 2, para 1, presented at 24 weeks of gestation. She had received prenatal care in our department since early pregnancy. The prenatal ultrasound examination performed before 24 weeks of gestation was uneventful, but progressive microcalcifications of the placenta were noted subsequently. The entire placenta was covered with small calcified spots. Her past gynecologic and obstetric history was notable for having been a very low birth weight baby (1,450 g, delivered at 29 weeks preterm), and for having had a very low body mass index of 16–18 kg/m 2 since childhood. Her general condition was normal, except for frequent common colds. At the time of her second pregnancy, her body weight was 38 kg and her height was 150 cm. Her body mass index was 17 kg/m 2 (normal, 22–25 kg/m 2 ). Her first pregnancy had occurred 2 years earlier and severe placental microcalcifications had developed, along with IUGR by 27 weeks of gestation. Her baby was delivered at term by cesarean section because of breech presentation. The baby weighed 2,450 g. The histopathologic findings of the placenta were unremarkable except for grade III chorioamnionitis. Placental microcalcifications developed earlier during her current pregnancy, at 24 weeks of gestation. The snow-like small calcified spots were scattered around the entire placenta (Figures A–C), but did not occur on the fetal parts of the placenta. Symmetric IUGR was noted at 32 weeks of gestation, earlier than in her last pregnancy. Steroid supplementation (betamethasone 12 mg intramuscularly every 24 hours for 2 doses) was given for lung maturation. The screening results for toxoplasmosis, other congenital syphilis and viruses, rubella, cytomegalovirus, and herpes simplex virus were unremarkable and she had no intrauterine infection, as with her previous pregnancy. She underwent cesarean delivery at 36 weeks of gestation because of severe IUGR, with an estimated fetal weight of 2,200 g. A healthy baby was delivered, with no obvious perinatal problems. Placental calcium deposition is a normal physiologic process that occurs throughout pregnancy. During the first 6 months, the microcalcification is microscopic;

Steroid Cell Tumor-A Rare Type of Ovarian sex-cord Stromal Tumor

Summary: We here report a rare case of ovarian sex-cord stromal tumor, a steroid cell tumor. A 30-year-old female, para 2, visited our department for absence of menstruation period for three consecutive months. The transabdominal ultrasound showed an irregular solid tumor about 6 cm in diameter over left adnexa with some ascites. The laboratory data including blood count, electrolytes, and hormone profiles all showed within normal limits except elevation of serum testosterone (2.63 ng/mL). During the operation, we found an irregular solid tumor about 6 cm in diameter with some yellowish ascites over cul-de-sac. The frozen section of the tumor showed obscured cell type with marked vessels proliferation. Left salpingoophorectomy was done because of the uncontrollable bleeding from the tumor. The tumor was totally solid and bright yellowish in gross and the permanent pathological examination proved to be a benign-looking steroid cell tumor of not otherwise specified (SCTNOS). The clinical presentations of the ovarian sex cord-stromal tumor are according to the cell type. The case we present here showed amenorrhea and hyperandrogenicity.

Isolated Congenital Diaphragmatic Hernia in the Third Trimester: A Case Report and Literature Review

OBJECTIVE To report a rare congenital anomaly, a right diaphragmatic hernia, in a near-term baby. CASE REPORT A 40-year-old female, gravida 3, para 2, had undergone regular prenatal care in our department since the early second trimester. She underwent amniocentesis at 16 weeks of gestation. The result showed normal 46,XY. Fetal growth was appropriate throughout the pregnancy. A small heart with marked left-side deviation was noted in the third trimester. The heart rate was less than 25% of normal. A homogenous mass with centralized vessels was noted in the fetuss right chest. The baby showed respiratory distress immediately after delivery. Imaging studies after birth proved there was a right diaphragmatic hernia with severe pulmonary hypertension and poor lung function. CONCLUSION Right congenital diaphragmatic hernia is rare. A prenatal diagnosis is difficult to make in the second trimester. Prognosis is greatly influenced by the associated abnormalities.