Diagnosis and management of a rare case with placental site trophoblastic tumor.

OBJECTIVE: Placental site trophoblastic tumor (PSTT) is rare and is characterized by a slow growth. The objective of this report is to present a case of PSTT associated with irregular vaginal spotting that occurred 1 year after normal vaginal delivery. CASE REPORT: This report provides interesting ultrasound, hysteroscopy, and histology findings of PSTT. It is difficult to make a clinical diagnosis of PSTT at an early stage. Without the use of immunohistochemical analysis, PSTT may evade histological detection. An operative hysteroscopy using electrocauterization reduces active bleeding during the removal of PSTT with markedly engorged tumor vessels. CONCLUSION: Transvaginal sonography using color Doppler imaging plays a vital role in identifying residual PSTT with microscopic infiltration to the myometrium and a negative serum ß-human chorionic gonadotropin level.

Prenatal diagnosis of mosaic small supernumerary marker chromosome 17 associated with ventricular septal defect, developmental delay, and speech delay.

OBJECTIVE: We present molecular cytogenetic characterization of mosaic small supernumerary marker chromosome (sSMC) derived from chromosome 17. MATERIALS AND METHODS: A 43-year-old woman underwent amniocentesis at 17 weeks of gestation because of advanced maternal age. Amniocentesis revealed a karyotype of 47,XY,+mar[12]/46,XY[15]. Parental karyotypes were normal. Array comparative genomic hybridization (aCGH) and metaphase fluorescence in situ hybridization (FISH) were applied on cultured amniocytes. Quantitative fluorescent polymerase chain reaction (QF-PCR) was applied on the DNAs extracted from cultured amniocytes and parental bloods. The parents elected to continue the pregnancy. Conventional cytogenetic analysis on peripheral blood of the neonate was performed at age 2 months and 11 months. aCGH was performed on the peripheral blood at age 11 months. RESULTS: aCGH on cultured amniocytes revealed a result of arr 17q11.1q11.2 (25,372,965-27,725,134)×3.2 (Log2 ratio = 0.73) compassing NOS2, POLDIP2, NEK8, and TRAF4. Metaphase FISH analysis revealed a result of +mar .ish der(17)(D17Z1+, wcp17+)[4/5]. QF-PCR assays excluded uniparental disomy 17. The marker chromosome was the sSMC(17) of der(17)(:p11.1→q11.2:). A 3004 g male baby was delivered at 38 weeks of gestation. Ventricular septal defect, neonatal developmental delay and speech delay with language problems were noted at neonatal follow-ups. The peripheral blood at age 2 months had a karyotype of 47,XY,+mar[11]/46,XY[29]. The peripheral blood analysis at age 11 months revealed a karyotype of 47,XY,+mar[27]/46,XY[13] and the aCGH result of arr 17q11.1q11.2 (25,616,440-27,822,571)×2.5 (Log2 ratio = 0.34). CONCLUSION: aCGH is useful in the precise measurement of the involved size of the euchromatic material and the associated genes in prenatally detected sSMC.

Enhanced cytotoxicity of natural killer cells following the acquisition of chimeric antigen receptors through trogocytosis.

Natural killer (NK) cells have the capacity to target tumors and are ideal candidates for immunotherapy. Viral vectors have been used to genetically modify in vitro expanded NK cells to express chimeric antigen receptors (CARs), which confer cytotoxicity against tumors. However, use of viral transduction methods raises the safety concern of viral integration into the NK cell genome. In this study, we used trogocytosis as a non-viral method to modify NK cells for immunotherapy. A K562 cell line expressing high levels of anti-CD19 CARs was generated as a donor cell to transfer the anti-CD19 CARs onto NK cells via trogocytosis. Anti-CD19 CAR expression was observed in expanded NK cells after these cells were co-cultured for one hour with freeze/thaw-treated donor cells expressing anti-CD19 CARs. Immunofluorescence analysis confirmed the localization of the anti-CD19 CARs on the NK cell surface. Acquisition of anti-CD19 CARs via trogocytosis enhanced NK cell-mediated cytotoxicity against the B-cell acute lymphoblastic leukemia (B-ALL) cell lines and primary B-ALL cells derived from patients. To our knowledge, this is the first report that describes the increased cytotoxicity of NK cells following the acquisition of CARs via trogocytosis. This novel strategy could be a potential valuable therapeutic approach for the treatment of B-cell tumors.

Complete resolution of diffuse placenta increta in a primigravida with twin pregnancy: sonographic monitoring.

We report a case of timely diagnosis of placenta increta by sonography during the third stage of labor, which avoided any attempt at manual removal of a retained placenta and thus prevented additional postpartum bleeding. The use of intra-cervical injection of vasopressin and methotrexate and application of transcatheter arterial embolization of bilateral uterine arteries and right internal iliac arteries resulted in a good outcome.

Prominent decidual vasculature overlying the internal cervical os: an entity potentially leading to acute life-threatening antepartum hemorrhage.

We report a new entity of prominent decidual vasculature overlying the internal cervical os which caused life-threatening antepartum uterine bleeding in a rhesus (Rh) D-negative patient at 32(+5) weeks' gestation. Cesarean hysterectomy was performed because of diffuse placenta increta. Early hospitalization, advanced preparation for emergency cesarean section, and timely blood transfusion, including 2L of RhD-positive packed red blood cells, aided in saving the lives of the patient and her baby. To the best of our knowledge, the ultrasound findings of this condition have never been reported. This condition could be considered as an independent sign for identification of a patient who is potentially at risk of acute massive antepartum hemorrhage. It deserves early accurate diagnosis by obstetricians using transvaginal sonography with color Doppler analysis.

Adynamic ileus and acute colonic pseudo-obstruction occurring after cesarean section in patients with massive peripartum hemorrhage.

The clinical histories (including radiographs) of 4 patients who suffered from significant adynamic ileus or acute colonic pseudo-obstruction after cesarean section are presented. The main manifestations were vomiting, severe colicky pain, and abdominal distension. These can occur immediately after or within 2 days of the operation. Based on our experience, the risk factors for the development of adynamic ileus are significant peripartum hemorrhage leading to unstable hemodynamic status, severe constipation, use of meperidine for pain relief, and overt bowel manipulation. Mild enema and metoclopramide seem to be helpful in facilitating its resolution. Here, we examine how to differentiate mechanical bowel obstruction from adynamic ileus and look at how to prevent the occurrence of adynamic ileus while minimizing its severity and shortening its clinical course.

Management of pregnant women with cardiac diseases at potential risk of thromboembolism--experience and review.

Over a 7-year period, the chart records of six pregnant women with cardiac diseases at potential risk of thromboembolism were reviewed. All six patients survived and recovered well eventually. LMWH and beta-adrenergic blocker were effective to deal with atrial fibrillation. Digitalis and dobutamine were beneficial to prevent heart failure resulted from degenerated porcine valve and dilated cardiomyopathy. In a patient with mechanical mitral valve, low-dose warfarin did not cause fetal malformation, and was effective to prevent thrombus formation. Protamine sulfate was safely administered to neutralize intravenous heparin effect before vaginal delivery. Life-threatening postpartum pulmonary hemorrhage occurred as a result of pulmonary hypertension with an aberrant right pulmonary artery, absolutely necessitating a long-term cardiopulmonary bypass resuscitation. Patient with primary pulmonary hypertension gave birth safely with forceps assistance under epidural anesthesia. From literatures reviewed and successful experiences presented here, prenatal correction of the underlying cardiac malformation, precise switch of anticoagulant administration, optimizing cardiac function, early delivery prior to heart failure, postpartum fluid restriction, minimized peripartum blood loss, and meticulously intensive cares are essential to achieve satisfactory outcomes.

Potential role of intravenous immunoglobulin in the management of peripartum maternal thrombocytopenia due to various causes.

Severe maternal thrombocytopenia resulting in hemorrhage is often associated with high mortality. Three cases of severe maternal thrombocytopenia in association with heparin-induced thrombocytopenia (HIT), HELLP syndrome, and systemic lupus erythematosus (SLE) were successfully managed using intravenous immunoglobulin (IVIG). IVIG can reduce the severity of thrombocytopenia and hemolysis, stabilize lupus activity, prevent peripartum hemorrhage, and shorten hospitalization, but it may induce reversible interstitial nephritis and membranous glomerulonephritis. IVIG may be beneficial in the management of severe peripartum maternal thrombocytopenia in association with HIT, HELLP syndrome, and SLE.

A novel technique to apply a Seprafilm (hyaluronate-carboxymethylcellulose) barrier following laparoscopic surgeries.

OBJECTIVE: To describe a novel technique for application of a Seprafilm (modified hyaluronate-carboxymethylcellulose) barrier laparoscopically, and to assess the adequacy of coverage of desired sites. DESIGN: Retrospective cohort study. SETTING: University tertiary hospital. PATIENT(S): One hundred twenty-seven patients who underwent fertility-sparing laparoscopic surgery. INTERVENTION(S): The Seprafilm was rolled up in a plastic package, then delivered through the main trocar. It was unrolled and positioned to cover the traumatized surface of the uterus, ovaries, and tubes. During application, the pelvis was photographed, videotaped, and the pictures were reviewed by two surgeons. MAIN OUTCOME MEASURE(S): The adequacy of the application was divided into three levels as to whether the Seprafilm could cover all the traumatized surfaces. RESULTS: Of the first 15 patients, 4 of 15 (26%) had successful coverage of the traumatized surface with the first sheet of Seprafilm. Of the following 112 patients, 97 of 112 (86.5%) had successful coverage with the first sheet. The success rate climbed to 96% after the second or third sheet. The average time for the application of six pieces (one sheet cut into six pieces) was 21 +/- 4 minutes. The posterior cul-de-sac is difficult to apply well. CONCLUSION(S): It is feasible to apply the antiadhesion barrier Seprafilm laparoscopically. Further studies will be needed to assess the efficacy of reducing adhesion following such use.

Iatrogenic abscess at uterine incision site after cesarean section: sonographic monitoring.

A woman with a large abscess at the site of a uterine incision after a cesarean section was successfully managed without hysterectomy. To my knowledge, transvaginal sonographic monitoring of the healing of an abscess at the site of a uterine incision has not been reported. Although in this case it was possible to preserve the uterus, the possibility of a weak uterine scar remains.