Acardiac Twin Presented as a Lower Extremity: Case Report with Serial Prenatal Ultrasonography

An acardiac twin is one of the very rare anomalies that occurs in monochorionic twins and the incidence of this is about one out of 35,000 births. We present the serial prenatal ultrasound findings, along with the postnatal histologic correlation, of an acardiac twin that manifested as a single lower extremity.

Acute Sheehan's syndrome with hyponatremia and hypoglycemia / 대한산부인과학회지

We report two cases of acute Sheehan's syndrome with a brief review of literature: A 28-year-old woman who had been performed cesarean section delivery complicated by hemorrhage due to uterine atony. And a 29-year-old woman who had vaginal birth after cesarean section (VBAC) complicated by hemorrhage due to birth canal laceration. On 8th day after delivery, both patient visited emergency room in critical condition with nausea, vomiting and general weakness. Although clinically significant Sheehan's syndrome is an uncommon consequence of obstetric hemorrhage, Sheehan's syndrome should be considered in the differential diagnosis of hyponatremia and suggestive hypoglycemia in early postpartum period women with history of massive obstetric hemorrhage.

Sister Mary Joseph's nodule from advanced ovarian carcinoma / 대한산부인과학회지

Umbilical metastasis may be the first presenting sign of the disease, or an indication of a recurrence from a previous malignancy. We recently encountered a 19-year-old woman with advanced ovarian adenocarcinoma whose first sign was having a Sister Mary Joseph's nodule. This patient only presented an umbilical nodule with slight lower abdominal discomfort, without any other subjective symptom. The lesion was fresh red, firm, ulcerating and has 1.5 cm in diameter. A punch biopsy from the lesion revealed metastatic adenocarcinoma and a PET-CT scan showed hypermetabolism on the umbilicus. After a systemic evaluation, she had a laparotomy including right salpingo-oophorectomy, total omentectomy, pelvic and paraaortic lymphadenectomy, appendectomy, and extirpation of the umbilicus. The patient received a postoperative combination of chemotherapy with paclitaxel and carboplatin, and still remains alive. This case demonstrates the importance of careful evaluation of any umbilical lesion and pathologic examination.

A Case of Preeclampsia Complicating a Pregnancy with Malignant Neurofibromatosis / 대한주산의학회잡지

Neurofibromatosis type 1 (NF-1) is one of the most common genetic disorders, occurring once in every 4000 births. The prevalence of neurofibromatosis associated with pregnancy was one in 5000~18500 deliveries. Higher rates of maternal and neonatal complications have been reported in NF-1 patients including as hypertension, intrauterine growth restriction (IUGR), preterm labor, stillbirth and cesarean section rates. Thus, pregnant patients with NF-1 are required close antenatal observation at high risk tertiary centers in order to detect complication early. We report a case of malignant neurofibromatosis associated with pregnancy with a review of literature.

The diagnostic value of saline infusion sonohysterography in evaluation of patients with abnormal uterine bleeding / 대한산부인과학회지

OBJECTIVE: To evaluate saline infusion sonohysterography (SIS) as an investigative modality in abnormal uterine bleeding of premenopausal and postmenopausal women. METHODS: Eighty eight patients, 74 premenopausal women and 14 postmenopausal women, with abnormal uterine bleeding were selected. After complete work-up, transvaginal examination were performed followed by SIS. The final surgical-pathologic findings were compared with the results obtained from transvaginal sonography (TVS) and SIS. The sensitivity, specificity, positive and negative predictive value were calculated for each procedure. RESULTS: The SIS was perfomed in 85 cases. It couldn't be done in one premenopausal woman and two postmenopausal women. The uterine cavity was normal in 28 women, 57 cases displayed abnormalities. Seventeen had endometrial polyp, 17 had submucosal myoma, 23 had irregular endometrium. We found that SIS missed five endometrial polyp and mislabeled 14 (38.9%) false positive endometrial growth. On comparing SIS, transvaginal sonography missed nine endometrial polyp and mislabeled 22 (55%) false positive endometrial growth. The sensitivity, specificity, positive predictive value and negative predictive value of TVS were 72.9%, 45%, 61.4% and 58.1%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of SIS were 87.8%, 61.1%, 75.4% and 78.6%, respectively. Sensitivtity and negative predictive value were significantly higher with SIS than TVS. CONCLUSION: The SIS is a safe, convenient, time conserving, cost effective, easily accessible and acceptable investigative modality. It definitely enhance the diagnostic potential of TVS in accessment of endometrium and intracavitary pathologies in women with abnormal uterine bleeding.

A new scoring system for differentiation between benign and malignant ovarian masses / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to design a new scoring system for differentiation between benign and malignant ovarian masses and to assess effectiveness of new scoring system comparing other scoring systems. METHODS: This study was based on 199 women who visited Soonchunhyang Hospital for surgery of ovarian mass. Ultrasonography and scoring system based on De Priest, Sassone, Ferrazi and Alcazar was performed the day before operation. Pathologic diagnosis after operation was directly compared with diagnosis of scoring system. The cut-off level of the new index is 11 points. This study was evaluated by sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: Parameters of new scoring system were wall thickness, number of septum, volume of mass, irregularity, vascularity and echogenicity. The new scoring system had sensitivity 73.9%, specificity 97.7% and negative and positive predictive values of 96.6% and 80.9% respectively. CONCLUSION: Sensitivity of new scoring system was similar to previous ones but specificity of that is higher. Our new scoring system shows better to differentiate benign from malignant ovarian mass than four other scoring systems.

Overexpression of p16(INK4A) as a biomarker for ASCUS in ThinPrep(TM) smear / 부인종양

OBJECTIVE: The overexpression of p16(INK4A) is induced by human papillomavirus (HPV) and associated with the carcinogenesis of cervical epithelia. So, immunostaining of p16(INK4A) may be useful biomarker in detecting CIN of cervix uteri in abnormal cervical lesions. The potential of p16(INK4A) as a biomarker for Atypical squamous cells of undetermined significance (ASCUS) examined in liquid-based specimens. METHODS: We collected samples 30 cases of ASCUS in Thinprep(TM) smears between March 2003 and August 2003. 23 control Thinprep(TM) cases were included; 10 negative for intraepithelial lesions, 13 cervical squamous intraepithelial lesions. p16(INK4A) immunochemial staining was performed on 53samples. At the same time, we tested another cervical swabs of patients by the Hybrid Capture II(TM) test. The cut off value was scored positive if it contained above 5 abnormal cells with nuclear and cytoplasmic immunostaining. RESULTS: The results of p16(INK4A) immunochemial staining comparing with one of HC II(TM) showed negative results with low kappa coefficient of 0.034. The sensitivity of p16(INK4A) immunochemial staining were 30.8% and the specificity were 82.4% respectively (p<0.01). p16(INK4A) is a useful marker for the detection of the cervical intraepithelial neoplasia but is not ASCUS. CONCLUSION: Immunostaining of p16(INK4A) is not useful triage test in detecting abnormal lesion of ASCUS in liquid-based specimens.

Comparison of the solution of ThinPrep(TM) Pap test with the Cervical Sampler(TM) of Hybrid Capture (HC) II for detecting Human papillomavirus (HPV) DNA / 부인종양

OBJECTIVE: Our purpose was to compare the difference and the positivity rate between Preserv Cyt(TM) solution of Thin-Prep(TM) Pap test and Cervical Sampler(TM) of Hybrid Capture II for detecting HPV DNA. METHODS: We collected samples of the cervix by using Preserv Cyt(TM) solution of Thin-Prep(TM) Pap test and a Cervical Sampler(TM) of Hybrid Capture II from ninety one women who screened for cervical carcinoma and precancerous cervical lesions between January 2003 and March 2003. At the same time, we tested the sample using the Preserv Cyt(TM) solution left over with a sample conversion kit. The cut off value for positive test result was above 1 pg/mL. RESULTS: The results of comparing the test using the Preserv Cyt(TM) solution of Thin-Prep(TM) Pap test with the one using Cervical Sampler(TM) showed negative results and 34 patients showed positive results with a significant high kappa coefficient of 0.674. The HPV titer of 10. Agreement rates of Preserv Cyt(TM) solution according to the HPV titer of Cervical Sampler(TM) were as follows: 97.7% in values below 1, 96.8% in values above 10, but 17.6% in values 1 to 10. So, the agreement rate was low between Cervical Sampler(TM) and Preserv Cyt(TM) solution in low value of HPV of Cervical Sampler(TM). CONCLUSION: Comparing the test using Preserv Cyt(TM) solution with Cervical Sampler(TM), there was a high correspondence and the Preserv Cyt(TM) solution was facilitated to detection for HPV at a time.

A Case of Primary Carcinoma of the Fallopian Tube / 대한산부인과학회잡지

Primary tubal carcinoma is a rare carcinoma of the female genital tract, comparising with only 0.3% to 1% of female genital tract malignancies. Its histologic appearance and clinical behavior resemble that of primary ovarian carcinoma, thus the evaluation and treatment are also essentially the same. Presenting symptoms are variable, so pre-operative diagnosis is rare. A postmenopausal women presented with pelvic mass and vaginal discharge. It was initially diagnosed as ovarian tumor but primary carcinoma of the fallopian tube was confirmed postoperatively on the basis of the pathologic examination of resected specimen. So, we reported a case with a brief review of the concerned literature.

A Case of Fetal Bilateral Reanl Agenesis Diagnosed by Prenatal Ultrasonography / 대한산부인과학회잡지

Fetal bilateral renal agenesis is a lethal congenitlal anomaly. An early and prenatal diagnosis is extremely important, because it may offer options for pregnancy termination as early as possible. The criteria for the ultrasonographic diagnosis of bilateral renal agenesis are severe oligohydramnios, nonvisualization of the bladder, and the empty renal fossae. However, severe oligohydramnios makes it difficult to diagnose the disease because of poor sonographic resolution. We present a case of fetal bilateral renal agenesis diagnosed by ultrasonography at 21 weeks gestation.

A Clinical study of Intrauterine Fetal Death / 대한산부인과학회잡지

OBJECTIVE: The purpose of this study was to evaluate intrauterine fetal death and elucidate the etiology of intrauterine fetal death. METHODS: This is a clinical study of 74 cases of intrauterine fetal death (IUFD) among 5,523 deliveries at Soonchunhyang University Hospital during Jan. 1998 to Apr. 2003. RESULTS: The overall incidence of IUFD was 1.34%. And the age distribution of mother with IUFD was between 19 to 44 year old and was highest in the 25 to 29 year old age group (39.1%). The parity of mothers with IUFD was the highest in nulliparous group (78.3%) and there was a decreased tendency with high parity. There were 47 cases (63.5%) with previous history of abortion and 2 cases (2.7%) with previous history of IUFD. The highest incidence rate of IUFD was shown at 20-24 weeks of gestation (48.6%) and in the fetus weighted less than 1,000 gm (59.5%), and the sex ratio of male versus female fetus was 1:1.07. The modes of delivery were labor induction (54.1%), laparotomy (18.9%), spontaneous labor (27.0%). The indication for laparotomy was placental abruption, placenta previa, previous cesarean section state. The etiology factors of IUFD were unexplained causes (55.4%), cord complication (12.2%), placental abruption (9.4%), placenta previa (9.4%) in order. CONCLUSION: The causes of IUFD were unexplained, cord complication, placental abruption in order. So, the proper antenatal care should be taken of fetuses on the basis of risk factors of antepartum and intrapartum.

Postnatal outcome of Prenatally detected Fetal Hydronephrosis / 대한주산의학회잡지

OBJECTIVE: To help prenatal counselling in fetal hydronephrosis by demonstrating the postnatal investigation, treatment and outcome of infants with hydronephrosis prenatally diagnosed. METHODS: Between January 2000 and December 2001, we studied 20 infants who presented with fetal hydronephrosis confirmed by postnatal ultrasonography. In the postnatal follow-up period, the infants were followed with sequential ultrasonography and urinalysis. (99m)Tc-DTPA scan, intravenous pyelography and voiding cystourethrography were performed in selected cases. An anteroposterior renal pelvic diameter >7 mm after 30 weeks of pregnancy was defined as fetal hydronephrosis. Follow-up ranged from 6 to 18 months (mean, 12). RESULTS: Unilateral hydronephrosis was diagnosed in 13 infants and bilateral in 7. A male predilection was found (4:1) and the left kidney was more commonly involved. If there was no resolution, ultrasonographic follow-up was done until 18 months. As a results, hydronephrosis resolved in 11, who were all in the unilateral hydronephrosis group. The range of the fetal renal pelvis on prenatal ultrasonography was 7~13 mm in the resolution group. Pyeloplasty was performed in two unilateral hydronephrosis infants. CONCLUSION: When the fetal renal pelvis was below 14 mm at least on prenatal ultrasonography, it didn't progress. Fetal hydronephrosis below 14 mm may be safely observed, and surgical correction was performed only a few infants. So, we suppose that this outcome must be considered enough in prenatal counsellings and that the work-up for more many people is needed, because of the small number of the patients whose renal pelvic diameter is above 14 mm in this study.

A Case of Thrombotic Thrombocytopenic Purpura in Pregnancy / 대한산부인과학회잡지

Thrombotic thrombocytopenic purpura (TTP) is quiet rare, with 1 of 25,000 delivery and complicating pregnancy is associated with high maternal mortality and long-term morbidity. Unfortunately the clinical appearance of thrombotic thrombocytopenic purpura is similar with the syndrome of hemolysis, elevated liver enzyme, and low platelet (HELLP), but the treatment of this differs from that of the HELLP syndrome or acute fatty liver of pregnancy, therefore accurate diagnosis is essential for optimal therapy. The survival of this disorder has been improved due to aggressive treatment with plasma transfusion or plasmapheresis. We have experienced a case of thrombotic thrombocytopenic purpura confused with HELLP syndrome of preeclampsia, so we report it with a brief review of literature.

Partial Trisomy 2q(2q37.3->qter)and Monosomy 7q(7q34->qter) Due to Paternal Reciprocal Translocation 2;7: A Case Report

We report an unbalanced translocation involving chromosome 2 and 7 due to a balanced reciprocal translocation 2;7 in the father. The female fetus had a partial trisomy of the long arm of chromosome 2 with a partial monosomy of distal 7q. Ultrasound at the first trimester had indicated normal fetal anatomy, including normal intracranial structures. Parental karyotypes showed a paternal balanced translocation: 46,XY,t(2;7)(q37.3;->q34). The unbalanced translocation in the fetus resulted in trisomy for 2q37.3 qter and monosomy for 7q34->qter. Postnatal examination showed that the female abortus had a cleft lip and palate, and mild dysmorphic features. The clinical phenotype was in agreement with previous descriptions and allowed us to propose a fetal phenotype for this chromosomal abnormality.

A Case of Normal Vaginal Delivery in the Pregnant Woman after Treatment of Pulmonary Edema During Dextran Therapy of the Sudden Deafness / 대한산부인과학회잡지

Dextran of a low molecular weight (dextran 40) is frequently used to improve regional perfusion after surgery in spite of the potentially serious complications such as noncardiogenic pulmonary edema, oliguric renal failure, and coagulopathy that have been widely reported. Dextran is used to improve cochlear microcirculation in sudden deafness of vascular origin, but the frequency of complications is rarely reported in the field of otolaryngology. We reviewed the literature of a case we experienced in which a pregnant woman, after recovering from pulmonary edema caused by treatment for sudden deafness with dextran, had a successful vaginal delivery.

A comparison of intravaginal misoprostol with intravenous oxytocin for labor induction at term / 대한산부인과학회잡지

OBJECTIVE: To compare the safety and efficacy of intravaginally administered misoprostol (PGE1 analogue) versus intravenously administered oxytocin for labor induction at term. METHODS: Among 63 patients over 37 weeks, randomly selected 42 patients were vaginally administered 25 micro gram of misoprostol every 3 hours and the other 21 patients were intravenously administered every minute from 1 mIU/min to 10 mIU/min increasingly. RESULT: The average interval from initiation of induction to labor was notably shorter in oxytocin group than in misoprostol group (204.5+/-332.6 min versus 528.1+/-591.8 min, p<0.02). The average interval from initiation of induction to vaginal delivery was shorter in oxytocin group than in misoprostol group (414.4+/-309.4 min versus 528.1+/-519.8 min, P<0.01) and the difference has statistical meaning. Procedure of labor were divided by 3 stages. We checked the duration of each stage between the two comparative groups. 1st stage (242.7+/-150.14 min versus 605.5+/-805.8 min, P<0.05) 2nd stage (12.6+/-11.9 min versus 19.5+/-11.2 min, P<0.05) The stage duration of oxytocin group was shortened. There was no difference between two groups at the third stage. The incidence of tachysystole, hypertonics, hyperstimulation, meconium passage, abnormal fetal heart rate, fetal weight, apgar score, neonatal morbidity were not different between two group. CONCLUSION: Intravenously administered oxytocin was more effective in shortening labor time than intravaginally administered misoprostol in overall induction labor, but there was no notable difference in the effects on mothers and babies. Considering various situational factors, careful selection should be administered.

A Case of Partial Hydatidiform Mole with a Coexistent Live Fetus / 대한산부인과학회잡지

Hydatidiform moles are generally separated into two classifications. Complete hydatidiform moles are characterized by cystic swelling of all villi, often pronounced diffuse trophoblastic hyperplasia, lack of fetal parts, all 46 chromosomes of paternal origin (androgenesis). Partial hydatidiform moles appear to be focal trophoblastic hyperplasia, a fetus or indications of previous fetal existence, 69 chromosomes. Hydatidiform mole with coexistent fetus is a very rare phenomenon, with an estimated incidence of 0.005 to 0.01 percent of all pregnancies and associated with a risk of persistent gestational trophoblastic tumor. Recently, hydatidiform moles with a fetus have become more common due to use of assisted reproductive technology. Most patients with hydatidiform mole and coexisting normal fetus must cautioned about the potential for risks of malignant change and severe medical complications, such as preeclampsia, hyperthyroidism and antepartum hemorrhage, that may necessitate prompt pregnancy termination. We experienced a case of partial hydatidiform mole with coexistent live fetus, which was diagnosed by ultrasonography at 15 gestational weeks. A brief reviews of related literature was done.

A Case of Endometrial Ossification Treated by Ultrasound-guided Dilatation and Curettage / 대한산부인과학회잡지

The endometrial osseous metaplasia is one of a rare conditions which gynecologist experience clinically. Clinical presentation may include irregular menstration, abnormal uterine bleeding, discharge, dysmenorrhea, pelvic pain, and secondary infertility. However the etiology and treatment about this disease are unclear. Recently, ultrasound-guided management of ectopic bone in uterus was suggested more potentially safer based on reported multi-patients women, a large majority was successfully treated. We have experienced a case of endometrial osseous metaplasia diagnosed and treated by ultrasound-guided dilatation and curettage. Which is presented with a brief review of literatures.

Effect of Endotoxin on Insulin-like Growth Factor-1 Expression in Small Intestine and Intrauterine Growth of Rabbit Fetus / 대한산부인과학회잡지

OBJECTIVE: New Zealand White Rabbits were utilized to determine whether fetal insulin-like growth factor-1 (IGF-1) expression in small intestine is altered in response to maternal enodotoxin administration. STUDY DESIGN: Six pregnant rabbits were intramuscularly injected with lipopolysaccharide of E. coli (serotype 055:B5) 30 microgram/kg, whereas normal saline 0.3 mL/kg were injected to the other six pregnant rabbits on gestational day 25 and 26. Fetuses were harvested on gestational day 27 and were identified as favored (Fav) or runt (Runt) depending on the location in the uterus. Fetal weight and small intestinal length were recorded. Three parts of small intestine (proximal, middle and distal) were collected. Reverse transcription polymerase chain reaction (RT-PCR) was used to measure IGF-1/beta-actin mRNA densitometric band ratios. Statistical analysis was performed using paired Student's t-test and Pearson correlation test. RESULTS: The ratio of mRNA IGF-1/beta-actin was lower in endotoxin group (0.80+/-0.24, n=24) than control group (1.13+/-0.31, n=24, P0.05). CONCLUSION: In our study, maternal endotoxin administration suppressed IGF-1 production in small intestine of fetal rabbit. Endotoxin in maternal serum might be transferred to fetus through placenta and decreased production of mRNA of IGF-1 in small intestine. Further studies are warranted to investigate the correlation between intrauterine growth retardation and maternal gram negative bacterial infection.

Study on the Factor V Leiden Mutation in Pregnant Women and Relationship with Preeclampsia Severe Form / 대한주산의학회잡지

OBJECTIVE: A study showed that resistance to activated protein C may develope some cases of severe preeclampsia. A common missense mutation in the factor V gene, the Leiden mutation, is the most frequent genetic cause of resistance to activated protein C. Our objective was to determine whether this mutation is more prevalent in patients with severe preeclampsia than in normotensive controls. METHOD: Deoxyribonucleic acid was extracted from whole blood of 158 gravid women of severe preeclampsia and 403 normotensive gravid women. The polymerase chain reaction was used to amplify exon 10 of the factor V gene, followed by allele-specific restriction with Mnl 1 for mutation detection. RESULTS: No patients were homozygous for the Leiden mutation. We could not find any positive case with FV:Q506 in the normal or patient group. CONCLUSION: We could not find that carriers of the factor V Leiden mutation are increased risk for severe preeclampsia. In contrast to the reports in Caucasian, the prevalence of APC resistance and FV:Q506 might be very low or absent in the Korean population. But, carriers of this common thrombophilic mutation may be identified so that other causes and risk factors for inherited thrombophilia should be investigated in the Korean population.