Opciones e indicaciones en el manejo del istmocele / Options and indications in the management of isthmocele

INTRODUCCIÓN: El istmocele es un defecto en la cicatrización del sitio de una histerotomía, que puede cursar con sangrado posmenstrual, dolor pélvico, dismenorrea, dispareunia e infertilidad secundaria. Esta patología ha ido incrementando su prevalencia dado el aumento de la tasa de cesáreas en todo el mundo. OBJETIVO: Se realizó una revisión sobre el istmocele y su manejo, presentando sus indicaciones específicas y las complicaciones asociadas a esta patología. MÉTODO: Se llevó a cabo una búsqueda en PubMed, Embase, Scopus y Google Scholar, en la que se encontraron 868 artículos, de los cuales se revisaron 30 al aplicar los criterios de inclusión y exclusión. DISCUSIÓN: El istmocele es cada vez más frecuente. Tiene una prevalencia cercana al 60% posterior a la realización de una cesárea y aumenta hasta valores del 100% con tres de ellas. Los métodos diagnósticos más utilizados son la ecografía transvaginal y la histerosonografía. Su abordaje es habitualmente quirúrgico, aunque existe la posibilidad de intentar tratamiento médico en algunos casos. CONCLUSIONES: Es necesario determinar el grosor miometrial para poder establecer un plan de manejo adecuado. Además, se ameritan estudios que realicen un seguimiento a largo plazo y que aporten mayor evidencia para la realización de cada procedimiento. Después de clasificar el tipo de defecto, el tratamiento quirúrgico del istmocele se debe ofrecer a pacientes sintomáticas y a aquellas con defectos grandes y que desean mantener la fertilidad.

INTRODUCTION: The isthmocele is a defect in the healing of the site of a hysterotomy, which can present with post-menstrual bleeding, pelvic pain, dysmenorrhea, dyspareunia and secondary infertility. This pathology has been increasing its prevalence given the increase in the rate of cesarean sections worldwide. OBJECTIVE: A review will be carried out of the isthmocele and its management, presenting its specific indications and the complications associated with this pathology. METHOD: A search was carried out in databases such as PubMed, Embase, Scopus and Google Scholar, finding a total of 868 articles, of which 30 of them were reviewed when applying the inclusion and exclusion criteria. DISCUSSION: Isthmocele is an increasingly frequent pathology, having a prevalence of 60% after performing a cesarean section and increasing to 100% with 3 of them. There are multiple diagnostic methods, mainly transvaginal ultrasound and sono-hysterosonography. The approach to this pathology is usually surgical, although there is the possibility of trying medical treatment in some cases. CONCLUSIONS: It is necessary to determine the myometrial thickness in order to establish an adequate management plan. Additionally, long-term follow-up studies are warranted and provide more evidence for the performance of each procedure. After classifying the type of defect, surgical treatment of the isthmocele should be offered to symptomatic patients or those with large defects and who desire future fertility.

Desenlace fatal en embarazadas contagiadas con la COVID-19 / Fatal outcome wiht pregnant and COVID-19

Introducción: Múltiples han sido las muertes y contagios por el nuevo coronavirus. En medio de este contexto el contagio de la enfermedad en pacientes embarazadas ha sido bien documentado. Objetivo: Presentar los eventos ocurridos en embarazadas para transmitir la experiencia a quienes tratan estas pacientes. Presentación del caso: Se expone el caso de una gestante de 24 años, obesa, con embarazo de 25 semanas. Fue ingresada con neumonía por COVID-19 y evolución hacia la insuficiencia respiratoria grave que fallece durante la cesárea. Se recibió en el quirófano con hipoxemia e hipercapnia, taquicardia, cianosis, oliguria y ventilada a presión positiva con oxígeno al 100 %. Se conduce con ketamina, fentanilo y rocuronio. A los 35 min, y posterior a la histerotomía, presentó bradicardia progresiva, por lo que se inicia compresiones torácicas externas y tratamiento farmacológico. Se recuperó el ritmo sinusal a los 12 min, pero recidiva la parada en asistolia a los 20 min, con cianosis en esclavina. Se implementó compresiones y administración de epinefrina hasta fallecer 30 min después por no recuperación de ritmo y signos ciertos de la muerte. Conclusiones: La atención multidisciplinaria mejora las condiciones de tratamiento en todas las etapas. El manejo anestésico individualizado ofrece una estrategia invaluable en casos como estos, independientemente del resultado. El tromboembolismo pulmonar en la gestante es un riesgo latente y asociado a la COVID-19, incrementa, exponencialmente, su letalidad.

Introduction: Multiple deaths and infections due to the new coronavirus have occurred. In the midst of this context, the spread of the disease in pregnant patients has been well documented. Objective: Present the events that occurred in pregnant women, in order to share the experience with those who treat these patients. Presentation of the case: The case of a 24-year-old pregnant woman, obese, with a pregnancy of 25 weeks is presented. She was admitted with COVID-19 pneumonia and evolution towards severe respiratory failure led to her death during cesarean section. She was received in the operating room with hypoxemia and hypercapnia, tachycardia, cyanosis, oliguria and ventilated at positive pressure with 100% oxygen. She was treated with ketamine, fentanyl and rocuronium. At 35 min, and after hysterotomy, she presented progressive bradycardia, so external chest compressions and pharmacological treatment were initiated. The sinus rhythm was recovered at 12 min, but the asystole stop relapsed at 20 min, with cyanosis. Compressions and administration of epinephrine were implemented until death 30 minutes later due to non-recovery of rhythm and certain signs of death. Conclusions: Multidisciplinary care improves treatment conditions at all stages. Individualized anesthetic management offers an invaluable strategy in cases like these, regardless of the outcome. Pulmonary thromboembolism in pregnant women is a latent risk associated with COVID-19, exponentially increasing its lethality.

Retos durante la realización de cesáreas perimorten / Challenges during the performance of perimortem cesarean section

Introducción: El paro cardiaco en gestantes y la cesárea perimorten son infrecuentes. Estas constituyen catástrofes médicas que precisan atención inmediata. Realizar este proceder según normas adecuadas brinda mejores opciones a la madre y el feto. Cuba presta especial atención al binomio materno fetal, para ello emplea grandes recursos humanos y tecnológicos. Objetivo: Actualizar la información acerca de cesárea perimorten. Métodos: Se realizó una revisión en bases de datos que permitiese encontrar descripciones epidemiológicas, informes de casos, series de casos, comunicaciones personales, y estudios en diferentes contextos sanitarios, los cuales sirvieran de evidencia científica del tema. Resultados: El paro cardiaco en embarazadas es un evento infrecuente, la realización de una cesárea perimorten con tiempo reducido (4-5 min) resultó una opción efectiva. El trabajo del equipo multidisciplinario basado en protocolos tiene una función que beneficia tanto a la madre como al feto. Actualmente se recomienda el concepto de histerotomía resucitadora que refleja la optimización de los esfuerzos realizados en la reanimación. La muerte materna por anestesia es una emergencia médica que requiere especial atención. Existen asociaciones médicas que preconizan las escalas de cuidados precoces en gestantes graves, con un entrenamiento actualizado y con estrategias novedosas para obtener mejores resultados. Conclusiones: El estudio del paro cardiaco en gestantes, la cesárea perimorten y la muerte materna relacionada con la anestesia son importantes. La creación de grupos multidisciplinarios y grupos bien entrenados son la mejor opción en estas circunstancias. Se recomienda incrementar el estudio y entrenamiento para ofrecer las mejores opciones al binomio materno-fetal(AU)

Introduction: Cardiac arrest in pregnant women and perimortem cesarean section are rare. These are medical catastrophes that require immediate attention. Performing this procedure according to adequate standards provides better options for both the mother and the fetus. Cuba pays special attention to the maternal-fetal binomial, for which large amounts of human and technological resources are used. Objective: To update the information about perimortem cesarean section. Methods: A database review was carried out to find epidemiological descriptions, case reports, case series, personal communications, and studies in different health contexts, which would serve as scientific evidence on the subject. Results: Cardiac arrest in pregnant women is a rare event; the performance of a perimortem cesarean section with reduced time (4-5 min) was an effective option. The work of the multidisciplinary team based on protocols has a function that benefits both the mother and the fetus. Currently, the concept of resuscitative hysterotomy is recommended, which reflects the optimization of the resuscitation efforts. Maternal death by anesthesia is a medical emergency that requires special attention. There are medical associations that advocate the scales of early care in pregnant women, with updated training and innovative strategies to obtain better outcomes. Conclusions: The study of cardiac arrest in pregnant women, perimortem caesarean section and anesthesia-related maternal death are important. The creation of multidisciplinary groups and well-trained groups are the best option in these circumstances. It is recommended to increase the study and training to offer the best options to the maternal-fetal binomial(AU)

Anesthesia for intrauterine myelomeningocele correction: first successful experience in Peru. Case report / Anesthesia for intrauterine myelomeningocele correction: first successful experience in Peru. Case report

Abstract Introduction: In pregnancies with a diagnosis of fetal myelomeningocele (MMC), studies have shown that prenatal correction, as compared with postnatal correction, results in better outcomes in infancy, requiring less ventriculoperitoneal shunts, and resulting in improved motor function of the lower limbs. However, maternal morbidity, the risk of uterine repair dehiscence, uterine rupture secondary to hysterotomy, and the need for cesarean section are all increased. This case report is the first successful experience of intrauterine repair of a MMC in Peru. Case presentation: We describe the case of a primigravida at 25 weeks of gestation with a diagnosis of fetal malformation (MMC and Arnold Chiari II syndrome) taken to intrauterine correction of the neural tube defect under general anesthesia plus epidural analgesia. Conclusion: The use of total intravenous anesthesia associated with nitroglycerine infusion for uterine relaxation, ethylephrine infusion to maintain maternal hemodynamic stability, and adequate postoperative pain management with epidural analgesia was successful in this case.

Resumen Introducción: En los embarazos con diagnóstico de Mielomeningocele fetal, los estudios han demostrado que la corrección prenatal conlleva a mejores resultados en la infancia que la corrección postnatal, requiriendo menos derivaciones ventrículo peritoneales y mejor función motora de miembros inferiores. Sin embargo se incrementa la morbilidad materna, el riesgo de dehiscencia de histerorrafia, ruptura uterina secundaria a la histerotomía y la necesidad de parto por cesárea. El presente reporte de caso es la primera experiencia exitosa de reparación intrautero de MMC en Peru. Presentación del caso: Describimos el caso de una primigesta de 25 semanas de gestación, con diagnóstico de malformación fetal (Mielomeningocele y Síndrome de Arnold Chiari II) en quien se realizó una corrección intrautero del defecto neural y cuya técnica anestésica fue anestesia general más analgesia epidural. Conclusiones: El uso de anestesia total intravenosa asociado a la infusión de nitroglicerina para la relajación uterina, la infusión de etilefrina para mantener la estabilidad hemodinámica materna y el adecuado manejo del dolor postoperatorio vía epidural fue exitoso en este caso.

The Present of Fetal Therapy and Future Prospect / 대한주산의학회잡지

Advances in prenatal diagnosis have led to the prenatal management of a variety of congenital diseases. Fetal surgery was born of clinical necessity. Observations by pediatric surgeons and neonatologists of neonates that were born with irreversible organ damage led to the conclusion that one possible approach to prevent this alteration of developmental physiology, was fetal surgical intervention. The demonstration in animal models that the correction of an anatomical defect could reverse the associated pathophysiology led to the first systematic application of fetal surgery at the University of California, San Francisco, in the early 1980s . There has been a dramatic improvement in our ability to diagnose, select and safely operate on an expanding number of fetal anomalies. Many fetal interventions remain investigational but for a number of conditions randomized trials have established the role of in utero surgery, making fetal surgery a clinical reality in a number of fetal therapy programs. Although prenatal stem cell and gene therapy await clinical application, they offer tremendous potential for the treatment of many genetic disorders. Here we review the prenatal evaluation, current status and future potential of various prenatal operative approaches, such as open hysterotomy, fetoscopy, and percutaneous, including tissue engineering, and prenatal cellular and genetic therapy.

Lamellar Body Counts in Fetal Rabbits' Experimental Diaphragmatic Hernia and Tracheal Ligation

Experimental tracheal ligation (TL) has been shown to reverse the pulmonary hypoplasia associated with congenital diaphragmatic hernia (CDH) and to normalize gas exchange. The purpose of this study was to determine whether the TL would correct the surfactant deficiency present in the fetal rabbit model of CDH by using lamellar body count. Lamellar bodies are synthesized and secreted by the type II pneumocytes of fetal lung. The phospholipids present in these bodies constitute the major component of pulmonary surfactant. Twenty-one pregnant New Zealand rabbits underwent hysterotomy and fetal surgery on gestational day 24. Two fetuses of each pregnant rabbit were operated. In the fetus of one end of bicornuate uterus, left DH was created by excision of fetal diaphragm through open thoracotomy (DH Group). In the fetus of the other end of bicornuate uterus, left DH and TL were created (TL Group). The fetuses were delivered by Cesarean section on gestational day 31. Fourteen in control group, 12 in the DH group and 13 in TL group were born alive. En bloc excision of lungs, bronchi and trachea was done in all newborn rabbits. A five Fr catheter was inserted through trachea and repeated irrigations with 10 cc normal saline were done. The irrigated fluid was centrifuged at 280 xg for 5 minutes and the lamellar bodies were counted with the upper level fluid in platelet channel of electronic cell counter. The average lamellar body counts were 37.1 +/- 14.2 x 10(3)/microL in control group, 11.5 +/- 4.4 x 10(3)/microL in DH group, and 6.5+/- 0.9 x 10(3)/microL in TL group. Lamellar body count in DH group was lower than in control group and did not increase after TL. This study shows TL has no therapeutic effect on decreased surfactant level of CDH and the pregnant rabbit is appropriate for the animal model of CDH.

A polêmica da histerorrafia na operação cesariana / The polemic of hysterorraphy on caesarean section

A histerorrafia no parto cesáreo constitui tempo cirúrgico nobre, pois a adequada cicatrização uterina poderá evitar as nefastas conseqüências da ruptura uterina, para a mãe e concepto, em futura gestação e parto. Essa técnica de sutura, entretanto, não apresenta uniformidade plena na literatura. Os métodos subsidiários de avaliação do estado da cicatriz uterina também não têm se mostrado eficientes e práticos. Há preferência pela utilização de fios absorvíveis sintéticos, principalmente em função da menor reação tecidual que promovem. Não é consenso, mas prevalece a opinião de que um único plano com sutura contínua tem melhor relação custo/benefício. A técnica de histerorrafia na cesariana também poderá variar de acordo com o grau de urgência e volume de sangramento no momento do procedimento.

The hysteroraphy in the caesarean section constitutes a right time surgical procedure, as the adequate uterine cicatrization will prevent the uterine rupture undesirable effects for the mother and concepto, future gestation and childbirth. This suture technique, however, does not present full uniformity in literature. The subsidiary evaluation methods on the state of the uterine scar have not been shown efficient and practical. There is preference for the synthetic absorvible thread use, mainly in relation to the lesser tecidual reaction that is promoted. It is not a consensus, but the prevailing opinion is that there is better cost/benefit relation in an only plan with continuous suture. The technique of hysterorraphy in the cesarian section may also vary according to the urgency level and bleeding volume at the procedure time.

A case of ectopic pregnancy in the previous cesarean section scar treated by transvaginal hysterotomy / 대한산부인과학회지

Implantation of a pregnancy within the scar of previous cesarean section is the rarest form of ectopic pregnancy. Delayed diagnosis and treatment can lead to uterine rupture, hemorrhage and maternal morbidity. But diagnosed early by transvaginal sonography, treatment options are capable of preserving the uterus and subsequent fertility. Suction curettage, exploratory laparotomy, laparoscopic surgery, systemic or local injection of methotrexate is the treatment method currently performed. In this report, we treated a case of this patient by transvaginal hysterotomy. This is the first case report in the recent literature. By this surgery, we could successfully remove gestational sac from the implantation site and repair the defect by primary suture and preserve uterus.

A case of ovarian endometriosis after laparoscopically assisted vaginal hysterectomy / 대한산부인과학회지

Endometriosis is defined as the presence of endometrial tissue outside the uterus and located usually within the pelvis. It may be detected as a rare complication associated with surgery. Endometriosis following obstetric and gynecologic procedure, which is localized mostly in the surgical scar including Cesarean section scar, hysterotomy scar, trocar scar, Bartholin cyst exision scar, or episiotomy scar, may caused by implantation of endometrial gland and stroma. Endometriosis developing after hysterectomy, especially, is a quite rare condition except a recurrent disease. We have experienced a case of a 47-year-old woman who had diagnosed ovarian endometriosis two years after laparoscopically assisted vaginal hysterectomy for a large leiomyomatous uterus with no evidence of endometriosis, so we report this case with a brief review of literature.

Two Cases of Acute Interstitial Pneumonia During the Second Trimester of Pregnancy / 대한주산의학회잡지

We present two cases of acute interstitial pneumonia (AIP) during the second trimester of pregnancy managed by mechanical ventilation, high dose corticosteroids. We described clinical course, laboratory data and imaging studies. Case 1) A 29-year-old woman, G1P1, was referred for aggravated continuous coughing, sputum and dyspnea, pleuritic chest pain and mild fever for 3 weeks at 24(+3) weeks of gestation. There were coarse breathing sounds with crackles on the both lung field. Her chest X-ray showed diffuse haziness in both lungs with suspicious nodular opacities and suggested pneumonia. HRCT showed diffuse ground glass opacities with interstitial thickening and suspicious fine nodular infiltration in both lungs suggesting acute interstitial pneumonia combined with ARDS. Because her symptoms were more aggravated, she was performed mechanical ventilation treatment. After that, she was performed cesarean hysterotomy and delivered a dead male 850grams. After her symptoms were much more improved. All antibiotics were stopped and reduced the doses of steroids, she was discharged with t-tube capped state. Case 2) A 33-year-old woman, G1P1, was referred for continuous coughing, sputum and dyspnea for 3 months and low abdominal discomfort at 24(+4) weeks of gestation. There were coarse breathing sounds with rales on the both lung field. Her chest X-ray showed diffuse haziness in both lungs with suspicious nodular opacities and suggested interstitial pneumonia. HRCT showed diffuse ground glass opacities with some intralobular and interlobular interstitial thickening and suspicious fine nodular infiltration in both lungs suggesting acute interstitial pneumonia or miliary TBc combined with ARDS. She was treated with antibiotics, oxygen, high dose corticosteroids, and tocolytics. There was no evidence of TBc in the bronchoscopy. She showed decreased mentality and decreased O2 saturation below 90% in spite of mechanical ventilation, high dose steroids and IVGV therapy. She delivered a boy of 870 g (Apgar score 1/5). After delivery, she was expired due to combined aggravating DIC. Her baby was expired at the next day, too. The outcome of AIP is fatal, reporting 59~100% mortality rate. The clinical course, laboratory data and treatment are not well established due to rarity of this disease entity. Chest X-ray and HRCT may be helpful in diagnosis and high dose steroid and immunosuppressive agents usually used but the efficacy is not guaranteed.

An uncommon cause of postpartum hemorrhage after cesarean section treated with selective arterial embolization: Pseudoaneurysm of the uterine pedicle / 대한산부인과학회잡지

This is a very important differential diagnosis for postpartum hemorrhage following cesarean delivery because repeated life-threatening bleeding may induce multiple blood transfusion and require emergency surgery including hysterotomy. False or pseudoanuerysm can be acquired in association with trauma, previous surgery, trophoblastic disease, neoplasm, infection or diethylstilbestrol exposure. When a punctured or lacerated artery does not seal completely, blood may escape and dissects the adjacent tissues, and collects in perivascular areas. If this collection maintains in communication with the parent vessel, a pseudoaneurysm could result. Typically the lesion are discovered because the patients have symptoms related to delayed rupture of the pseudoaneurysms, causing hemorrhage. Radiographic techniques (angiography, ultrasound, and magnetic resonance imaging) have provided the opportunity to diagnose pseudoaneurysm, arteriovenous malformation. We report a case of postpartum hemorrhage following cesarean delivery attributed to a pseudoaneurysm of the uterine pedicle and treated with arterial embolization. Angiographic study confirmed the diagnosis and embolization of the false aneurysm was successful in controlling the hemorrhage.

Diagnosis and Management of Pregnancies Implanted into the Lower Uterine Segment Cesarean Section Scar / 대한산부인과학회잡지

OBJECTIVE: To describe diagnosis and management of Cesarean section scar pregnancy increased at recently due to high Cesarean section rate. METHODS: Eleven cases of pregnancies implanted into the lower uterine segment Cesarean section scar were diagnosed and treated at Daegu Fatima hospital during January 1999 to May 2004. All cases are confirmed by transvaginal ultrasound scan. The management of Cesarean section scar pregnancies included transvaginal evacuation, hysterotomy and medical treatment with methotrexate systemic or local injection into gestational sac. RESULTS: Eleven Cesarean section scar pregnancies were diagnosed. Medical treatment was used in nine women and four women was successful. The success rate were 44% (4/9). Surgical treatment was used in two women included transvaginal evacuation and hysterotomy. Seven women (63%) required blood transfusion and one women (9%) had a hysterectomy. CONCLUSION: Cesarean section scar pregnancies are more common. When the diagnosis is made in early pregnancy the prognosis is good and prevent late pregnancy complication include placenta previa, placental accreta and uterine rupture. The risk of hystrectomy is relatively low.

A Case of Intramural Pregnancy in Uterus / 대한산부인과학회잡지

To our knowledge, implantation into the uterine muscle wall is one of the rare form of ectopic pregnancy, with only 16 cases reported until 1995. The early diagnosis depends upon the sonographic finding of intramural gestational sac-like growth and persistent high beta human chorionic gonadotropin (beta-hCG) levels after dilatation and curettage. But, nobody can't exclude intramural pregnancy in case that associated with adenomyosis in uterus in spite of negative beta-hCG. Hsieh et al. and Dousias et al. mentioned 2 cases of such situation with negative beta-hCG result. And confirmative diagnosis depends upon the pathologic finding for specimen obtained from laparoscopic or explorative hysterotomy. The authors have experienced one case of intramural pregnancy in uterus and report our case with a brief review of literature.

Two Cases of Endometriosis at the Subcutaneous Tissue of the Abdominal Scar after Cesarean Section / 대한산부인과학회잡지

Endometriosis is generally confined to the pelvic viscera and the peritoneum, but it can proliferate in other areas like pleura, skin, extremities, lung, gallbladder, stomach, kidney and surgical scar. Scar endometriosis usually occurs in the surgical scar of previous cesarean sections, hysterotomy and episiotomy. The occurrence of endometrioma in cesarean scar is an infrequent event, usually presenting as a tender abdominal wall mass. We report two cases of abdominal wall endometrioma after cesarean section, which is presented with a brief review of the literature.

Evaluation of Adnexal Mass associated with Pregnancy / 대한산부인과학회잡지

OBJECTIVE: To evaluate patients with adnexal masses that were managed surgically during pregnancy and their effect on fetal outcome. METHODS: The data were reviewed concerning pregnant women who required surgery at Samsung Cheil hospital between January 1996 to December 2001. Among 50,126 deliveries, 255 cases of ovarian tumors were evaluated for clinical aspects, histologic patterns, and obstetrics and fetal outcome. RESULTS: 1. The prevalence of ovarian mass in pregnancy was 0.5% (255 cases in 50,126 deliveries). 14 cases of malignant tumors were founded. 2. The maternal mean age was 28.7+/-3.6 years old, mean gavida was 1.8+/-1.1, and mean parity was 0.3+/-0.5. 3. The mean gestational weeks of diagnosis was 11.9+/-8.6 weeks. Prenatal operations were performed in 160 cases, and 95 cases of ovarian masses were operated at delivery time by cesarean section. 4. In the group of prenatal operation, preterm delivery and caesarian section rate were decreased at operation before 23 gestational weeks (P<0.05). 5. In 42 cases, Emergency operations were done. Mean delivery weeks was 36.7+/-7.2 weeks and was earlier than elective operation group (P<0.05). 6. The mean size of ovarian mass was 9.5+/-3.8 cm. The pathologic features of the 255 lesions were as follows: 98 benign cystic teratomas, 43 mucinous cystadenomas, 31 endometriomas, 20 serous cystadenomas, 14 simple cysts, 14 paraovarian cysts, 6 follicular cysts, 5 corpus luteal cysts, 5 theca luteal cysts, 3 hydrosalpinx, 2 fibromas, and 14 malignant tumors. 7. The 231 patients for whom the outcome of pregnancy was available, 18 (7%) gave birth before 37 weeks of gestation, while 3 (1.2%) experienced spontaneous abortions, 2 artificial abortions, and 1 hysterotomy. CONCLUSION: Most adnexal masses identified by sonography during pregnancy were small, simple cysts that did not pose a risk a pregnancy. However the percentage of malignant tumors or tumors of low malignant potential was 1.8 fold greater than previously reported. Surgical intervention at <23 weeks of gestation might have not been adverse outcomes.

A Case of Congenital Intracranial Immature Teratoma / 대한산부인과학회잡지

Congenital intracranial teratoma is a very rare tumor. We recently experienced a case of massive congenital intracranial teratoma that discovered in a male infant of 28 weeks of gestation. A 33-year old multigravida was observed at 28 weeks gestation for prenatal ultrasound examination and ultrasonography revealed the fetus was severely macrocephalic with marked hydrocephalus. For therapeutic termination, Hysterotomy and fetal cephalocentesis was performed to deliver a stillborn infant. Autopsy revealed a 2,420 g male infant with severe macrocephaly. A multilobulated intracerebral tumor was found a diameter 18 cm involving both cerebral hemisphere. The tumor was considered to have originated in the vicinity of pineal gland and suprasellar region. Microscopic examination showed the characteristic picture of a teratoma. The predominent component is immature neuroepithelium in the form of primitive neural tubules variably mature somatic tissure from other germ cell layers accompany the neuroepithelium. We report a case of congenital intracranial immature teratoma.

Extrauterine Placental Support of Goat Fetuses Using Arteriovenous Bypass / 대한마취과학회지

BACKGROUND: The extrauterine fetal incubation system must meet stable blood gas exchange and sufficient oxygen supply to provide the physiologic oxygen consumption of the fetus. In the fetus, blood gas exchange is totally sustained by the placental circulation. The placenta can be regarded as an extracorporeal organ, and the basic structure of placental circulation comprises arteriovenous (AV) bypass. To mimic this mode of circulation, we used AV ECMO (extracorporeal membrane oxygenation) in the goat fetus, and attempted to achieve stable blood gas exchange and oxygen supply to the fetus. METHODS: Pregnant goats, weighting 30 - 35 kg, were anesthetized with N2O-O2-enflurane. We performed a cesarean section with a midline incision, and cannulated via the umbilical vessels after a hysterotomy, and connected the fetuses to an ECMO circuit. The fetus was transferred to an incubator containing normal saline mixed with antibiotics. Blood samples were obtained every 4 to 6 hours from the circuit for electrolytes, hemoglobin and blood gas analysis and arterial blood pressure and heart rate were monitored through the umbilical artery. Oxygen delivery and consumption were calculated from the measured parameters. Microscopic examinations of the liver, kidney and lung were performed 24 hours after ECMO to know the effect of AV ECMO on the circulation of the organ. RESULTS: AV ECMO was done for 24 hours in the six goat fetuses and the main cause of death was circulatory failure. Heart rates and blood pressure were stable during ECMO. Sodium bicarbonate was injected when mild acidosis occurred and blood gas exchange was maintained stable. Mean pump flow rate was 156 +/- 62 ml/min/kg and oxygen extraction ratio was 30.4%. The liver function tests were sustained within normal limits both before and 24 hours after ECMO, but BUN and creatininincreased beyond upper normal limits 24 hours after ECMO. Microscopic features of the liver and kidney showed congestion 24 hours after ECMO. The fetal lung after 24 hours of ECMO especially showed an increase of mature capillaries in the septum and wall of alveoli compared with the twin fetal lung. CONCLUSIONS: These results indicate that the extrauterine fetal incubation model used for this study was suitable to blood gas exchange and utility of oxygen for goat fetuses.

Experimental Diaphragmatic Hernia and Tracheal Ligation in a Fetal Rabbit Model

Despite of advances in perinatal management and treatment modalities, congenital diaphragmatic hernia (CDH) remains a frustrating problem. Although the sheep has been the most reliable experimental animal of fetal surgery in CDH, the rabbits has some possible advantages over sheep; lower cost, smaller body size, year-round availability, high number of fetuses per pregnancy, and short gestational period. The purpose of this study is to evaluate the feasibility of the animal model of CDH in rabbits. Twenty seven pregnant New Zealand rabbits underwent hysterotomy and fetal operation on gestational day 24 or 25. Two fetuses of each pregnant rabbit were operated. In the fetus of one end of bicornuate uterus, left diaphragmatic hernia was created by excision of fetal diaphragm through open thoracotomy (DH Group). In the fetus of the other end of bicornuate uterus, left diaphragmatic hernia was created and tracheal ligation by small-sized Surgiclip(R) (USSC, Norwalk, Conn., USA) was performed through cervical incision (TL Group). Among twenty seven pregnant rabbits, twelve were born alive with diaphragmatic hernia and eight were born alive with diaphragmatic hernia & tracheal ligation. The most commonly herniated abdominal organ was the left lobe of liver. In DH group, the lungs were hypoplastic with a decrease in lung weight/body weight ratio, a reduction in number of alveoli, an increase of vascular medial wall thickness of pulmonary arteries. The alveoli were immature with thick alveolar septum and increased interstitium. In TL group, the alveoli were more mature than that of DH group and no significant difference from control group was existed. Thus this study demonstrates that (1)Diaphragmatic hernia can be created in rabbits by fetal surgery, (2)Tracheal ligation can be performed in rabbits by fetal surgery, (3)Experimental diaphragmatic hernia results in pulmonary hypoplasia, (4)Concurrent tracheal ligation prevents pulmonary hypoplasia that resulted from diaphragmatic hernia. The above mentioned results show that pregnant New Zealand rabbit is appropriate as the animal model of CDH.

A Case of Cutaneous Endometriosis / 대한피부과학회지

Endometriosis is defined as the growth of endometrial tissue outside the uterine cavity and its occurrence is usually related anatomically to the uterus and its attachments. Cutaneous endometriosis occurs most commonly as a secondary process in scars after abdominal or pelvic procedures including hysterotomy, hysterectomy, cesarean section, episiotomy, and laparoscopy. Because of the rarity of cutaneous endometriosis, and the failure of the recognition of the correlation between the intensity of the pain and the menstrual cycle, the diagnosis can be easily missed. We present a case of cutaneous endometriosis occurred in the scar of a previous cesarean section in a 27-year-old woman.