Yuri Perlitz

Anaphylactic Shock during Hysteroscopy Using Hyskon Solution: Case Report and Review of Adverse Reactions and Their Treatment

Dextran 70 (Hyskon) solution, as many other substances, is in current use as distension medium during hysteroscopy. The advantages of Hyskon solution are its nonconductivity and immiscibility with blood, allowing good visibility during operative hysteroscopy. Adverse reactions to Hyskon are mainly attributable to the drugs antigenic properties and include severe anaphylactic reactions and fatalities. We report a case of anaphylactic shock during hysteroscopy using Hyskon solution as the distension medium, review the adverse reactions of Hyskon and summarize the treatment modalities used to decrease the incidence of the rare but serious adverse reactions with its use.

Prenatal Diagnosis of Fetal Cardiac Right Ventricular Diverticulum Disappearing at Three Months of Age

Congenital cardiac diverticula are transmural localized protrusions within the free wall of the ventricles. Right ventricular diverticula are rarely diagnosed during the fetal period, and due to their rarity, their natural history remains unclear. We present a case of prenatal diagnosis of right ventricular diverticulum at 22 weeks’ gestation. No other pathological findings were detected, the pregnancy and delivery were uneventful, and the diverticulum disappeared before the age of 3 months. Echocardiography of the infant at 1 year of age revealed no cardiac diverticulum or any cardiac anomaly and showed normal heart function. Literature review of all cases published to date reveal good outcome of right ventricular diverticula. We suggest reassuring our patients about the good prognosis of this cardiac anomaly.

Endometrial ablation using hysteroscopic instillation of hot saline solution into the uterus

OBJECTIVE To evaluate the clinical effectiveness and safety of endometrial ablation by hysteroscopic instillation of hot saline using the Hydro-Therm-Ablator (HTA) system. METHODS A total of 14 patients with menorrhagia, underwent the HTA procedure under general anethesia. Follow up of 9-18 months is reported. Three patients had undergone tubal ligation years before the procedure and one underwent it immediately after HTA at the same session. RESULTS One procedure was cancelled due to technical problems, and roller-ball ablation was performed. There were no procedure related complications. A total of 11 patients reported significant reduction in bleeding, or amenorrhea, 9-18 months after the HTA procedure. One patient, although eumenorrheic after the ablation, considered the procedure a failure and requested hysterectomy. One patient with menorrhagia 3 months after the procedure, had a second HTA ablation and is now amenorrheic. CONCLUSIONS This series of patients who underwent HTA ablation had successful reduction of menorrhagia to oligomenorrhea or amenorrhea.

Accidental delivery through a vaginal incision (laparoelytrotomy) during caesarean section in the second stage of labour

A 33 year old woman was admitted at 41 weeks of gestation for induction of labour. Her previous delivery was by caesarean section for fetal distress. The present pregnancy was uncomplicated. The estimated fetal weight by sonogram was 3900 grams. The woman received vaginal prostaglandin E2 followed by oxytocin and entered active labour. Epidural anaesthesia was used. She progressed to full dilatation of the cervix. The infants head remained at 12 station despite adequate contractions, and we decided to perform a caesarean section. A low transverse incision was used to deliver a healthy girl weighing 3820g. The uterus was exteriorised for closure. Only after complete closure of the incision did it become evident that a free vaginal ̄ap was present. The original closure, which had sewn the free edges of the cervix together, was taken down. The free edge of the anterior vaginal wall was then sewn 1 cm proximal to the free edge of the anterior cervix, reforming a fornix between the two. The remainder of the operation was without incident. Estimated blood loss was 1000mL. The womans postpartum course was uncomplicated and she was discharged on her fourth post-operative day.

Counseling for Fetal Macrosomia: An Estimated Fetal Weight of 4,000 g is Excessively Low

OBJECTIVE Because of the known complications of fetal macrosomia, our hospitals policy has been to discuss the risks of shoulder dystocia and cesarean section (CS) in mothers with a sonographic estimated fetal weight (SEFW) ≥ 4,000 g at term. The present study was performed to determine the effect of this policy on CS rates and pregnancy outcome. STUDY DESIGN We examined the pregnancy outcomes of the macrosomic (≥ 4,000 g) neonates in two cohorts of nondiabetic low risk women at term without preexisting indications for cesarean: (1) SEFW ≥ 4,000 g (correctly suspected macrosomia) and (2) SEFW < 4,000 g (unsuspected macrosomia). RESULTS There were 238 neonates in the correctly suspected group and 205 neonates in the unsuspected macrosomia group, respectively. Vaginal delivery was accomplished in 52.1% of the suspected group and 90.7% of the unsuspected group, respectively, p < 0.001. There was no difference in the rates of shoulder dystocia. The odds ratio for CS was 9.0 (95% confidence interval, 5.3-15.4) when macrosomia was correctly suspected. CONCLUSION The policy of discussing the risk of macrosomia with SEFW ≥ 4,000 g to women is not justified. A higher SEFW to trigger counseling for shoulder dystocia and CS, more consistent with American College of Obstetrics and Gynecology (ACOG) guidelines, should be considered.

Prenatal sonographic evaluation of the penile length.

To construct cross‐sectional reference range of the penile length during pregnancy, measuring it from the proximal edge of the corpus cavernosum to the tip of the glans penis.

Nonconventional Approach to Twin Pregnancies Complicated by Extremely Preterm Premature Rupture of Membranes of One Twin

The common management in most centers in cases of multiple pregnancies with preterm premature rupture of membranes (PPROM) before 22 weeks of gestation is termination of the pregnancy or the expectant approach. Expectant management of previable PPROM in twin pregnancies results in an increased rate of fetal and neonatal morbidity and mortality of both twins. Selective fetocide of the twin with early midtrimester rupture of membranes may improve the unfavorable pregnancy outcome of the remaining fetus. We report two successful cases of twin pregnancies complicated by extremely PPROM managed by selective fetocide of the affected twin, with an uneventful single pregnancy course and delivery of healthy newborns at 36 weeks of gestation.

Peripartum maternal transmission of extended-spectrum β-lactamase organism to newborn infants

The aim of this study was to determine whether the route of extended-spectrum β-lactamase (ESBL) transmission to hospitalized newborns was from their mothers during delivery. Neonatal intensive care unit (NICU) hospitalized newborns were sampled for ESBL presence by stool cultures on the first and fourth days of life. Mothers of ESBL-positive newborns were sampled for possible correlation detection. Bacteria isolates were molecularly identified and susceptibility tests for antibiotic agents were performed. Of the 225 newborns, 14 (6.2%) were ESBL positive, 10 (4.4%) were Escherichia coli positive, and 4 (1.7%) were Klebsiella pneumoniae positive. Among the 14 mothers of positive newborns, 13 (92.8%) were found ESBL positive and one mother of a newborn with E. coli carriage was found ESBL negative. Genes encoding for ESBL resistance were identified. Antibiotic sensitivity and resistance were tested. This study demonstrated that ESBL bacteria carrier neonates hospitalized in NICU may be a result of transmission from mother to baby during delivery.

Acute polyhydramnios in term pregnancy may be caused by multiple nuchal cord loops.

Acute severe polyhydramnios developing in the third trimester or at term is a rare condition. Although there are many possible fetal or maternal causes for this phenomenon, in the majority of cases a specific etiology cannot be found. We describe our imaging findings and management of a case of severe acute polyhydramnios developing at the 40th gestational week. A 24-year-old healthy mother of two children was referred to our obstetrics department at 41+2 gestational weeks of her third pregnancy owing to very recent distention of her uterus. Her pregnancy had been uneventful, including a 22-week sonographic anomaly scan. No other screening tests were performed during pregnancy. During a visit for a routine check-up 1 week earlier, a sonogram revealed normal amniotic fluid volume and adequate gross body and breathing movements. Current sonography at admission revealed severe polyhydramnios, reaching an amniotic fluid index of 40 cm. A Doppler examination of the umbilical cord discovered multiple cord loops wrapped around the fetal neck (Figure 1). A healthy baby was delivered by Cesarean section. The estimated amniotic fluid volume was approximately 2.5 L. The umbilical cord was tightly wrapped three times around the fetal neck, forming a bulk which limited the free movement of the neck, but no strangulation marks were evident around the baby’s neck. Third-trimester or term pregnancy acute onset polyhydramnios is rare, usually mild, and not associated with structural defects1. However, in the severe polyhydramnios state, in 75% of cases significant fetal abnormalities are found that predominantly involve the central nervous system, gastrointestinal tract, heart and genitourinary tract2. Esophageal atresia often leads to polyhydramnios, usually early in the third trimester3. We found some circumstantial evidence in the literature that impediment to swallowing by goiters4, cervical teratomas5–7 or skin abnormalities8 is associated with polyhydramnios. In our case, the lack of any of these abnormalities in the newborn makes it tempting to postulate that the bulky accumulation of cord loops around its neck may have limited the Multiple nuchal cord loops

Calponin levels in term laboring women

Abstract Objective: Calponin, a specific smooth muscle contraction regulatory troponin-like protein, is present in large quantities in uterine smooth muscle. Serum troponin levels rise in acute myocardial infarction, and creatine phosphokinase levels rise at high physical activity, both due to destruction of cardiac and striated muscle fibers. We hypothesize that the active labor process may cause uterine smooth muscle cell damage, which may result in rising maternal serum calponin levels. This was a preliminary study, searching for a new biomarker for preterm labor. Methods: The study group included laboring term primiparous women with a singleton fetus. The control group included similar demographic and pregnancy characteristics pregnant women not in labor. Maternal serum levels of calponin basic isoform were measured evaluated and compared in both groups. Results: Study group included 100 pregnant women. Calponin serum levels were higher in the active labor (794 ± 974 ng/mL) than in the group not in labor (591 ± 587 ng/mL), although it did not reach statistical significance. Gender and neonatal weight were similar in the two study groups. Conclusions: Calponin serum levels showed moderate elevation during active labor, compared to the levels in a cohort of pregnant comparable women at the same gestational weeks but not in labor.