The natural history of pericardial tamponade secondary to recurrent ovarian carcinoma - A case report and review of the literature.

•We report a case of malignant cardiac tamponade secondary to ovarian carcinoma•We emphasize the quick and fatal outcome of such a complication•It seems that aggressive treatment offers the longest overall survival.

Imaging of an atypical large perineal cyst diagnosed during pregnancy.

Perineal cysts are quite frequent, almost 2% of women developing symptoms related to Bartholin or Gartner cysts. In most cases these cysts derive from embryological remnants or ectopic tissue, or form as epithelial inclusion cysts. These structures are usually asymptomatic unless they are complicated by infection. We report the sonographic and magnetic resonance imaging characteristics of a large perineal cyst diagnosed during the first trimester of an uncomplicated pregnancy, followed by conservative management during pregnancy and surgical excision in the puerperium.

Starry sky pattern of fetal liver sonogram as first sign of twin-twin transfusion syndrome.

'Starry sky' liver is one of the most common sonographic patterns in diffuse liver disease. It is characterized by clearly identified portal venules due to diminished parenchymal echogenicity. In advanced cases of twin-to-twin transfusion syndrome (TTTS), volume overload is considered the key factor in the pathogenesis of cardiac dysfunction of the recipient twin. When right-sided failure occurs, the liver might show signs of edema and, as in acute hepatitis, the appearance of starry sky might develop. We present a case in which the sonographic appearance of starry sky liver, along with right-sided cardiac failure (tricuspid regurgitation), were the first signs of TTTS in monochorionic twins at 20 weeks. A short time later, at 21 weeks, other signs of overload and signs of worsening heart failure were noted, as the typical triphasic waves in the inferior vena cava were replaced by a biphasic flow profile. Twin 2 at that time had relative oligohydramnios. A few days later, relative polyhydramnios and edema of the placental domain of the recipient twin were also noted. To the best of our knowledge, this is the first case report describing this hepatic sonographic pattern as an early sonographic sign of TTTS.

Doppler and gray-scale sonographic classification of adnexal torsion.

OBJECTIVE: To propose, in cases with coiling of the ovarian vessels, a classification of severity of torsion based on Doppler and gray-scale ultrasound findings and to suggest a treatment strategy for each situation. METHODS: Seventeen patients were examined in a gynecological emergency room between December 1995 and February 2003 due to suspected adnexal torsion. Doppler and gray-scale ultrasound were used to visualize coiling of the ovarian blood vessels. Intraovarian flow was assessed by spectral Doppler and on this basis, along with the patient's clinical condition, the decision was made as to whether surgery was necessary. Findings on surgery were recorded. RESULTS: All 17 patients showed coiling of the ovarian vessels. Nine had arterial and venous blood flow within the ovary and ultrasound and surgical findings usually demonstrated normal sized or mildly enlarged ovaries. Five had only arterial blood flow within the ovary and surgery usually revealed enlarged ovaries with normal color or mild discoloration. Three had neither arterial nor venous blood flow within the ovary, with vessel coiling evident only on gray-scale and not on Doppler examination, and surgical findings included signs of ovarian ischemia or necrosis. CONCLUSION: In cases of coiling of the ovarian vessels, Doppler flow analysis of the ovary can help differentiate between ischemic adnexal torsion and coiling of the ovarian blood vessels without strangulation, aiding in the choice of treatment. According to type of blood flow seen on Doppler examination, we suggest the following classification of severity of adnexal torsion and treatment strategy: Class 1, coiling with arterial and venous ovarian blood flow; a conservative approach may be considered if the clinical condition permits; Class 2, coiling with arterial ovarian flow but no venous flow; surgical intervention is required; and Class 3, true strangulation, with no ovarian blood flow; urgent surgical intervention is required.

The outcome of patients with stage I endometrial cancer involving the lower uterine segment.

The objective of this study was to evaluate whether lower uterine segment involvement (LUSI) correlates with recurrence and survival in women with stage I endometrial adenocarcinoma and whether it is associated with poor prognostic histopathologic features. Three hundred seventy-five consecutive patients with endometrial carcinoma stage I compromised the study population. The patients were divided into two groups according to the presence of LUSI with endometrial carcinoma. The two groups were compared with regard to prognostic factors and outcome measures by using the Pearson chi(2) test, log-rank test, and Cox proportional hazards model. LUSI was present in 89 (24%) patients with stage I endometrial carcinoma. LUSI was significantly associated with grade 3 tumor (P = 0.022), deep myometrial invasion (P < 0.0001), and the presence of capillary space-like involvement (CSLI) (P = 0.003). Kaplan-Meier survival curves demonstrated that patients with LUSI had a lower recurrence-free survival (log-rank test; P = 0.009) and a worse overall survival (log-rank test; P = 0.0008). In the Cox proportional hazards model, only a trend toward higher recurrence rate (HR = 2.4, 95% CI 0.7, 8.2; P = 0.16) and a trend toward poorer overall survival (HR = 1.54, 95% CI 0.82, 2.91; P = 0.18) were noted when LUSI was present. In patients with stage I endometrial cancer, the presence of LUSI is associated with grade 3 tumor, deep myometrial invasion, and the presence of CSLI. A larger group of patients is necessary to conclude whether higher recurrence rate and poorer overall survival are associated with the presence of LUSI.

The management of an early-missed abortion after radical trachelectomy--a case report and a review of the literature.

UNLABELLED: Radical trachelectomy (RT) has been reported for almost 20 years. This case report describes and addresses the issue of the clinical management of early-missed abortion in a patient after RT with a cerclage. CASE: A 35-year-old woman who had a RT 2 years ago due to cervical carcinoma stage IB1 presented with a missed abortion of an 8-week gestational age. At the end of the RT, a cerclage suture was inserted in the remaining internal oss of the cervix. The patient went through a cervical dilatation followed by suction curettage guided by ultrasonography without compromising the cerclage. This case report suggests that dilatation and suction curettage without compromising the cervical cerclage is a feasible option in the clinical management of early abortion in a patient after RT.

Computerized nuclear morphometry for the prediction of inguinal lymph nodes metastases in squamous cell carcinoma of the vulva.

This study evaluated the sensitivity and specificity of computerized morphometry in predicting lymph nodes metastases (LNM) in patients with squamous cell carcinoma (SCC) of the vulva. Histologic samples obtained from 20 consecutive cases of SCC of the vulva with positive inguinal LNM were morphometrically assessed and compared with samples from 20 consecutive cases of vulvar SCC negative for LNM. Computerized morphometry was performed on tumor cells and on adjacent nonneoplastic epithelial cells located 2-4 mm from the tumor margins. Computerized morphometric variables of tumor cell nuclei in patients with negative LNM significantly differed from those in patients with positive LNM. Morphometric differences in nuclear size and contour regularity were detected when comparing the nonneoplastic nuclei adjacent to the tumor of both groups. Multivariate analysis showed that the only independent predictors of LNM were the depth of the invasion (P= 0.005) and the mean nuclear roundness of the nonneoplastic nuclei adjacent to the tumors (P= 0.008). Using these variables, a discriminant score revealed a sensitivity of 90% and a specificity of 86.4% for predicting LNM in SCC of the vulva. Our data suggest that cells from the primary tumors with LNM differ morphometrically from primary tumors with no LNM. In addition, normal epithelial cells adjacent to the tumor express morphometric changes between the two groups. The results of our study justify the need for a prospective study of a larger number of patients to evaluate the reproducibility and the clinical use of the data.

Increased endometrial thickness in women with hypertension.

OBJECTIVE: We noticed an increase in endometrial thickness in women with hypertension who were treated with a combination of medications, including beta-blockers. The purpose of this study was to examine whether the endometrium of hypertensive women is thicker than that of healthy women and to determine whether endometrial thickening in hypertensive women is directly related to the antihypertensive beta-blocker treatment. STUDY DESIGN: We compared 3 groups of postmenopausal patients as follows: (1) women with a history of essential hypertension treated with a combination of medications, including beta-blockers; (2) women with a history of hypertension treated with a combination of medications that did not include beta-blockers; and (3) healthy women without hypertension. All patients were interviewed and examined, blood tests were performed, and endometrial thickness in the anterior-posterior diameter was measured by vaginal ultrasonography. Among the exclusion criteria were diabetes or an abnormal fasting blood glucose level, obesity, hormonal medication or replacement hormonal therapy during the previous 6 months, and a history of hormonal disturbances, infertility, or polycystic ovary syndrome. RESULTS: Of 45 hypertensive women enrolled in the study, 22 were treated with a beta-blocker combination medication and 23 were treated with other antihypertensive medications. They were compared with 25 healthy women. There was no statistically significant difference in endometrial thickness between women treated with medications, including beta-blockers, and those who were treated with other hypotensive agents. Twenty percent of women with hypertension and none of the healthy women had endometrium >5 mm thick (P <.017; odds ratio, 8.22; 95% confidence interval, 1.22-infinity). CONCLUSION: Twenty percent of hypertensive postmenopausal women were found to have increased endometrial thickness. However, we were unable to substantiate an association between the type of treatment administered, whether beta-blockers were included, and the increase in endometrial thickness.

Uterine curettage following second trimester abortion by extraovular instillation of prostaglandin E2. A prospective-randomized trial.

OBJECTIVE: To evaluate the benefits associated with routine uterine curettage following complete second trimester termination of pregnancy by extraovular prostaglandin E2. STUDY DESIGN: Fifty-five patients between 15 and 24 weeks' gestation who had undergone complete termination of pregnancy by continuous extraovular instillation of prostaglandin E2 (PGE2), were randomly assigned into either no further intervention (n=25), or uterine curettage under general anesthesia (n=30). The need for late uterine curettage, clinical and ultrasonographic parameters at 1 and 42 days follow-up, as well as the incidence of the minor and major complications, were compared between groups. RESULTS: Baseline and post-abortion clinical and ultrasonographic characteristics were similar in both groups. Mean (+/- Standard error of the mean) number of post-abortion bleeding days in the curettage group was 8.9+/-1.8 versus 10.1+/-2.6 days in the non-curettage group (P=NS). No patient in the former group, compared to three patients in the latter group, needed late uterine curettage, (P=NS). Major and minor complications rates in the curettage and in the no-curettage groups were not significantly different. Considerably more patients in the curettage group needed analgesic agents following the abortion compared to the no-curettage group (60% vs. 3.3%, respectively; P<0.001). CONCLUSIONS: Routine uterine curettage in patients undergoing complete second trimester termination of pregnancy by extraovular instillation of PGE2, exerts no benefit.

Fetal acrania: five new cases and review of the literature.

Acrania is a lethal malformation in which there is an absence of the flat skull bones covering the brain. Five new cases are described, and a review of the English-language medical literature is presented. The sonographic differential diagnosis of acrania includes anencephaly, large cephalocele, osteogenesis imperfecta, and hypophosphatasia. The diagnosis of acrania can be established sonographically even in the first trimester if a large mass of disorganized brain tissue covered only by a thin membrane is detected.

Activated protein C resistance (factor V Leiden) associated with thrombosis in pregnancy.

OBJECTIVE: Our purpose was to evaluate activated protein C resistance phenotype and genotype among patients with thrombosis during pregnancy and the puerperium. STUDY DESIGN: This observational study was conducted prospectively during a 2-year period (July 1993 to June 1995) in a preselected population. All patients admitted to our high-risk pregnancy unit with a diagnosis of deep vein thrombosis, pulmonary emboli, transient ischemic attack, and cerebrovascular accident during pregnancy and the puerperium were included. Prothrombin time, partial thromboplastin time, fibrinogen levels, protein C, protein S, antithrombin III, functional test for activated protein C resistance, and factor V Leiden mutation by polymerase chain reaction were performed on each patient. RESULTS: Fifteen patients were included. Seven (46.6%) patients were positive for activated protein C resistance (factor V Leiden). All other coagulation studies were negative for all patients. All patients with activated protein C resistance had a venous thrombotic event, deep vein thrombosis, or pulmonary emboli, and only one had a cerebrovascular accident on the basis of sagittal sinus thrombosis. Only two of the activated protein C resistance-negative patients had venous thrombosis (pulmonary emboli). The remaining six patients had transient ischemic attacks or cerebrovascular accidents. For the subgroup with venous thrombosis during pregnancy and the puerperium, the incidence of activated protein C resistance (factor V Leiden) was 78%. CONCLUSION: This study demonstrates the incidence of factor V Leiden in a selected population in whom thrombotic events developed during pregnancy and the puerperium. This small-scale study provides justification for a large cohort study that will identify women with factor V Leiden and determine their risk for thrombosis during pregnancy and the puerperium. We believe that factor V Leiden should be evaluated in conjunction with thrombotic events in the pregnant woman.

Supplementing iron intravenously in pregnancy. A way to avoid blood transfusions.

OBJECTIVE: To determine the safety and efficacy of maternal intravenous iron administration to avoid blood transfusion in patients who cannot use oral preparations. METHODS: Patients with persistent iron-deficiency anemia who had one of the following indications were included in this study: severe side effects from oral preparations, lack of improvement despite oral iron intake or history of gastrointestinal operations. The total iron amount needed to regenerate iron stores was calculated according to hemoglobin and the patients' weight. Hemoglobin, hematocrit, mean corpuscular volume, serum iron, transferrin and ferritin were evaluated at the start and conclusion of therapy as well as two weeks afterward. RESULTS: Twenty-six patients were included in the study; four of them delivered during the therapy course. One patient developed mild signs of allergy (urticaria) after the test dose and was excluded from the study. The remaining 21 pregnant patients (mean gestational age 28 weeks) completed the therapy course and received a mean of 1,000 mg of elemental iron. The hemoglobin was increased from 8.4 +/- 1.0 to 10.1 +/- 0.6 g/dL at the start and end of therapy, respectively (P < .01) and continued to rise to 10.9 +/- 0.6 g/dL two weeks later (P < .01). The serum iron was increased from 3.9 +/- 2.0 mumol/L at the start of therapy to 15.5 +/- 7.2 at the end (P < .01). The transferrin was decreased from 47.0 +/- 7.8 to 41.4 +/- 5.3 to 37.1 +/- 11.8 mumol/L at the start of, end of and two weeks after therapy, respectively (P < .01). Ferritin levels were increased from 2.9 +/- 2.7 ng/mL at the start to 122.8 +/- 87.1 at the end of therapy (P < .01) and decreased to 109.4 +/- 90.7 ng/mL two weeks after treatment (not significant). Only mild and transient side effects were occasionally reported. CONCLUSION: Intravenous iron administration during pregnancy is an effective method of regenerating hemoglobin and iron stores. It should be considered for patients with severe iron-deficiency anemia who cannot use oral preparations.

Ripening and dilatation of the unfavourable cervix for induction of labour by a double balloon device: experience with 250 cases.

OBJECTIVE: To determine the efficacy of the double balloon device (the Atad Ripener Device) in ripening and dilatation of the unfavourable cervix for induction of labour. METHODS: Two hundred and fifty women with unfavourable cervices (Bishop score < or = 4) underwent induction of labour with the Atad Ripener Device. Indications were pregnancy induced hypertension (n = 118), post-dates (n = 69), elective inductions (n = 23), other reasons including nonreassuring nonstress test, intrauterine growth retardation, previous caesarean section and diabetes mellitus (n = 40). The Atad Ripener Device was inserted into the cervix, the uterine balloon inflated in the internal os, and the cervico-vaginal balloon in the external os of the cervix (100 mL of normal saline to each balloon). Pressure produced by the inflated balloons caused gradual dilatation and effacement of the cervix. The Atad Ripener Device was removed 12 h after insertion, the cervix assessed again, and labour managed according to obstetrical criteria. RESULTS: The Atad Ripener Device caused an increase in the Bishop score in all subgroups with a mean change of 4.6 (from 2.0 prior to induction to 6.6 upon removal of the Atad Ripener Device; P < 0.05). The mean time interval from insertion of the Atad Ripener Device to delivery was 18.9 h, and from removal to delivery was 6.9 h. Caesarean section was performed in 39/250 patients (16%), and the others had a normal vaginal delivery. CONCLUSIONS: 1. The double balloon device induces significant ripening and dilatation of the unfavourable cervix. 2. Induction of labour was successfully achieved following removal of the Atad Ripener Device. 3. Our caesarean section rate was low compared with rates reported for women with an unfavourable cervix induced by other methods.

Indomethacin and fetal ductus arteriosus: complete closure after cessation of prolonged therapeutic course.

Indomethacin is a very effective tocolytic agent. However, concern about its possible constrictive effect on fetal ductus arteriosus has limited the use of this medication in pregnancy. A 29-year-old woman was treated with indomethacin at 27 weeks of gestation for preterm labor and polyhydramnios. She received a dose of 75 mg/day for 5 weeks. At 35 weeks of gestation, she had a cesarean delivery due to fetal distress, and a hydropic baby was delivered. The infant died shortly after. Nonimmune hydrops fetalis and closed ductus arteriosus were the only pathological findings at autopsy. In utero, irreversible, complete closure of the ductus arteriosus is very rare. In the case presented, prolonged use of indomethacin during pregnancy was associated with complete closure of the ductus arteriosus that developed most probably after discontinuation of therapy. This case emphasizes the need for frequent fetal echocardiography examinations during as well as after maternal indomethacin treatment.

Follow-up of small, postmenopausal ovarian cysts using vaginal ultrasound and CA-125 antigen.

To determine the natural history of small, simple ovarian cysts in postmenopausal women, 51 postmenopausal patients with small (< 5 cm), smooth, aseptate, hypoechogenic ovarian cysts, without ascites, were followed by vaginal ultrasound examinations every 3 months for an average period of 2.5 years. In 34, CA-125 antigen was measured and found to be within normal limits. None of the cysts showed changes in texture, nor did ascites appear. The CA-125 antigen serum levels remained low. The mean size of the cysts decreased with time. There was no statistically significant correlation between the initial size of the cyst, its tendency to grow or shrink, and the absolute CA-125 serum level. Our findings support the option of a conservative follow-up by repeated ultrasonic and CA-125 antigen examinations of small, simple cysts in postmenopausal women.

A randomized comparison of prostaglandin E2, oxytocin, and the double-balloon device in inducing labor.

OBJECTIVE: To compare the efficacy of three methods for ripening and dilating the unfavorable cervix for induction of labor. METHODS: Pregnant women having an indication for induction of labor with a singleton vertex fetus, intact membranes, and Bishop score of no more than 4 were randomized to one of three induction methods: intravaginal prostaglandin (PG) E2 tablets (3 mg) followed by a second dose if labor did not start; continuous intravenous oxytocin drip; or the Atad Ripener Device, with inflation of both balloons and removal after 12 hours. For all patients, the cervix was assessed by the same investigator before induction and 12 hours later. RESULTS: Thirty subjects were included in the PGE2 group, 30 in the oxytocin group, and 35 in the Atad Ripener Device group. The postpartum course was comparable in all. The change in Bishop score in the PGE2 and Atad Ripener Device groups was significantly better than in the oxytocin group (median and range of 5[0-9] and 5[0-7], respectively, versus 2.5 [0-9]; P < .01). Cervical dilation more than 3 cm was more frequent in the Atad Ripener Device group compared with both the PGE2 and oxytocin groups (85.7 versus 50 and 23.3%, respectively; P < .01). The trial of induction failed in only two patients (5.7%) in the Atad Ripener Device group, compared with six (20%) in the PGE2 and 16 (53.3%) in the oxytocin groups (P < .001). Mean (+/- standard deviation) induction-to-delivery interval was 21.3 +/- 7.0 hours in the Atad Ripener Device group, 23.2 +/- 12.5 hours in the PGE2 group, and 28.2 +/- 14.7 hours in the oxytocin group. The success rate for vaginal delivery was significantly better in the Atad Ripener Device and PGE2 groups compared with the oxytocin group (77.1 and 70%, respectively, versus 26.7%; P < .01). CONCLUSION: The Atad Ripener Device had a significantly better success rate for cervical dilation and a lower failure rate than those for PGE2 and oxytocin. The PGE2 and Atad Ripener Device groups had better results than the oxytocin group in regard to Bishop score change and induction-to-delivery interval. The Atad Ripener Device may be a superior method for cervical ripening and labor induction in patients with unfavorable cervices.

Diagnostic pitfalls of ultrasonographic uterine screening in women treated with tamoxifen.

Recent reports of an association between tamoxifen treatment for breast cancer and endometrial pathology prompted a screening program for women receiving tamoxifen. Twenty-two women were examined; 15 were asymptomatic, and 7 were referred because of abnormal vaginal bleeding. All underwent vaginal ultrasonography followed by endometrial sampling. The sonographic studies showed endometrial abnormalities in all 22 women--typically, irregular thickening of the endometrium. Some had cystic formations, and three had fluid in the endometrial cavity. No pathology or inadequate material was found in the endometrial samples from the 15 asymptomatic women. Endometrial polyps were suspected sonographically and removed from two of the five women with vaginal bleeding. The discrepancy between the sonographic findings and histology in the asymptomatic women could have been due to stromal edema from tamoxifen treatment. Abnormal ultrasonographic findings in asymptomatic women treated with tamoxifen probably represent insignificant changes in the endometrial architecture and not a true abnormality. The need for routine endometrial sampling or hysteroscopy in every case is therefore questionable.

Vaginal ultrasonography in patients with postmenopausal bleeding.

Our objective was to define a subset of women with postmenopausal bleeding in whom the accepted practice of endometrial sampling could be safely omitted. Vaginal endosonographic measurements were compared to the histological findings of curettings following diagnostic dilatation and curettage in 129 women with post-menopausal bleeding who were not receiving hormonal therapy. Atrophy was diagnosed in 49%, slight proliferation in 10%, endometrial polyps in 11%, hypoplasia in 12%, and adenocarcinoma in 12%. Endometrial atrophy was associated with a mean sonographic thickness of 2.6 mm of the double layer (range 0-6.5 mm). Of the women with a final histological diagnosis of atrophy, 92% had an endometrial thickness of 3 mm or less. Furthermore, all women with a sonographic endometrial thickness of 3 mm or less had atrophic endometrium (p < 0.0001). An endometrial thickness of 3 mm or less would have reduced the number of dilation and curettage procedures by 45% and no cases of endometrial pathologies would have been missed. In women presenting with postmenstrual bleeding, meticulous scanning of the endometrium can select a group where endometrial sampling can be omitted from the protocol.

Sonographic diagnosis of fetal congenital cataracts.

Five fetuses with congenital cataracts diagnosed in utero by ultrasound are reported. The fetuses, who were between 14 and 27 weeks' gestation, also had other severe malformations. The sonographic features of the cataracts are presented.