Zvi Katz

Spontaneous ovarian hyperstimulation syndrome concomitant with spontaneous pregnancy in a woman with polycystic ovary disease

Ovarian hyperstimulation syndrome has been described after treatment with exogenous gonadotropins, clomiphene citrate, and gonadotropin-releasing hormone. Spontaneous ovarian hyperstimulation syndrome has not been described before, except in association with hypothyroidism. We report on a case associated with spontaneous pregnancy, occurring in a woman with polycystic ovary disease.

Adult respiratory distress syndrome complicating ovarian hyperstimulation syndrome

A rare case of OHSS complicated by an ARDS from which the patient recovered after appropriate treatment is presented. Pulmonary capillary leakage induced by prostaglandin release, hypoalbuminemia, and shift of dextran 40 macromolecules to the intraalveolar space is considered the most probable reason for this complication.

MANAGEMENT OF PUERPERAL SEPARATION OF THE SYMPHYSIS PUBIS

Thirteen post‐partum patients with symphysiolysis were treated by intra‐symphysial injection of a combination of hydrocortisone, chymotrypsin and lidocain. The injection was given once a day and the full treatment consisted of between three to seven injections according to the severity of the symptoms. No other medication was given. Immediate relief was obtained in all cases after the first injection and all symptoms disappeared after the completion of treatment. The average time of hospitalization was 9.8 days. No complications were seen as a result of the treatment and the patients resumed their normal activities after being discharged from hospital. In comparison with other modes of treatment, the intra‐symphysial injection of the above drug combination shortened the time of morbidity and effected complete recovery.

Non-aggressive management of post-date pregnancies

A non-aggressive approach to the management of post-date pregnancies was tested in a clinical trial involving 156 patients who had reached 294 days of amenorrhea and had a pelvic score of 4 or less. Dates had been established with certainty in each case. In half of the patients (the study group) no time limit was imposed on the pregnancy, but the women were checked at frequent intervals for any increase in pelvic score and for changes in any of the following: fetal movement count recorded daily by the mother, an oxytocin challenge test, and amnioscopy. The pregnancy ended either through spontaneous contractions or through surgical induction carried out because of a change in any one of the parameters or an increase above 4 in the pelvic score. In the 78 control patients labor was induced surgically on day 294, even if the pelvic score was low. In the study group, labor started spontaneously in 52 patients; labor was induced in 17 women after they showed an elevated pelvic score, in 7 because of a pathologic parameter and in one because a mild pre-eclampsia developed. There were 7 cesarean sections in the study group compared with 16 in the control group (P less than 0.05). The average duration of labor was 6.7 h in the study group, compared with 9.4 h in the control (P less than 0.01). There was no significant difference between the two groups with regard to meconium staining during labor, pathologic fetal heart rate, or the 5 min Apgar score. In the study group there was one neonatal death as a result of severe congenital heart disease, and in the control group one infant died due to asphyxia. It is concluded that conservative management of prolonged pregnancies, with close supervision, gives better results than routine induction of labor at 42 wk. The importance of the pelvic score as an indication for induction is stressed. A protocol has been developed which can be used in cases of uncertain dates as well.

Ovarian Carcinoma Masquerading as Ovarian Hyperstimulation Syndrome

Two patients receiving ovulation‐inducing drugs were found to have ovarian carcinoma. Since patients receiving such medication are prone to develop enlarged ovaries with or without the fully developed hyperstimulation syndrome, the diagnosis of ovarian tumors in such patients may be delayed or missed. It is therefore being suggested that an ovarian enlargement persisting for more than 4 weeks, or the finding of ovarian solid masses by sonography in patients receiving ovulation‐inducing drugs, should lead to a thorough work‐up for neoplasia, sometimes including even laparotomy.

The outcome of pregnancies complicated by preterm rupture of the membranes with and without cerclage

Thirty‐two patients with cerclage were compared to 76 patients without cerclage. All pregnancies were complicated with preterm (<36 weeks) rupture of the membranes (PTROM). The management following removal of the cerclage was the same for the two groups and consisted of conservative treatment unless chorioamnionitis ensued. It was found that under similar conditions and treatment there was no significant difference between the outcomes of PTROM‐complicated gestations with and without a cerclage. The low added risk of cerclage to PTROM should not deter its use when indicated.

Laparoscopic cornuostomy in the treatment of interstitial pregnancy with subsequent hysterosalpingography

A 37 year old woman in her fourth pregnancy was admitted after six weeks of amenorrhea for evaluation of suspected ectopic pregnancy. A diagnosis of interstitial pregnancy was established by ultrasonographic examination. It revealed an empty endometrial cavity. In the left uterine corner an eccentric gestational sac 30 mm in diameter could be seen with no identifiable fetal pole. There was clear separation between the uterine cavity (endometrium) and the gestational sac. Serum levels of p subunit of human chorionic gonadotrophin (PhCG) were found to be rising: 4400 mIU/mL (2nd international standard), 5000 mIU/mL, and 6300 mIU/mL. Therefore, according to our protocol4, a laparoscopy was indicated. At laparoscopy the diagnosis of a 3 cm left interstitial pregnancy was confirmed. Both the tubes and the ovaries appeared normal. The technique of ‘comuostomy’ was similar to that used for tubal pregnancy: dilute vasopressin (0.5 U h L ) was injected, and a 1 -5 cm longitudinal incision was made electrosurgically through the myometrium and into the gestational sac. It should be einphasised that the needle must not be within a blood vessel because intravascular injection of vasopressin solution can precipitate acute arterial hypertension, bradycardia and even death’. The products of conception were removed by hydrodissection. The incision was left to heal by secondary intention. The bleeding was not excessive; nevertheless the patient was prepared to undergo the operation and the surgeon ready to perform an immediate laparotomy in the event of heavy bleeding. After the laparoscopy, the serum PhCG levels gradually decreased to < 5 mIU/mL. A hysterosalpingography was performed three months after the laparoscopy (Fig. 1). It revealed a normally shaped uterine cavity. The right fallopian tube appeared patent and normal, while the left tube had a distal occlusion. We assume that this distal occlusion or at least damage was present before the comuostomy.

Prenatal diagnosis of Meckel syndrome: alpha-feto protein and beta-trace protein in amniotic fluid.

Meckel syndrome was diagnosed prenatally by α‐feto protein and β‐trace protein determinations in amniotic fluid. No central nervous system anomalies were detected in the affected fetus, who presented with large polycystic kidneys and polydactyly. An excessive synthesis of these fetal proteins by the dysplastic kidneys is suggested, allowing for the possibility of prenatal diagnosis of polycystic kidneys in families at risk for this disease.

Constriction of the Umbilical Cord by an Amniotic Band After Midtrimester Amniocentesis

Abstract. Constriction of the umbilical cord by an amniotic band after previous midtrimester amniocentesis is an extremely rare entity. A case report of fetal asphyxia caused by partial occlusion of the umbilical cord by an amniotic band is presented. Clinical and experimental evidence strongly suggests that the pathogenesis of this defect is related to early rupture of the membranes during gestation with subsequent encirclement and ligation of fetal umbilical cord, or extremities. In this case, formation of the amniotic band caused by midtrimester amniocentesis is strongly suggested. Obstetricians should be aware of this hazardous complication during pregnancy and labor in women who had had a midtrimester amniocentesis.

Urinary Retention Caused by Impaction of Leiomyoma in Pregnancy

Complete urinary retention caused by incarceration of a retroverted gravid uterus or lagre fibroid uterus is a rare condition. the following case report illustrates the acute onset of urinary retention caused by the combination of a large leiomyoma and pregnancy. Total hysterectomy was performed. to the best of our knowledge, such a combination has not been reported previously.