Laparotomic myomectomy of a spontaneous perforated leiomyoma mimicking pseudomyxoma peritonei at 27 weeks of pregnancy.

OBJECTIVE: We report a rare case of acute abdomen pain in 27 weeks´ gestation caused by a perforated leiomyoma mimicking pseudomyxoma peritonei on magnetic resonance imaging. SUBJECT: Case report. SETTING: 1st Department of Gynaecology and Obstetrics. Faculty of Medicine, Comenius University in Bratislava, Slovakia. CASE REPORT: In our reported case report of perforated leiomyoma mimicking pseudomyxoma peritonei on magnetic resonance imaging. Successful myomectomy was done, and the pregnancy continued with good outcome. At week 40, the patient underwent caesarean section. CONCLUSION: Uterine fibroids in pregnancy can lead to severe complications. Their spontaneous rupture in pregnancy is very rare. To manage acute abdominal pain in pregnancy a good diagnostic must be performed, and surgical treatment should be carefully considered.

Placenta accreta as a cause of peripartum hysterectomy.

BACKGROUND: Our objective was to identify the risk factors associated with placenta accreta. METHODS: Cases of peripartum hysterectomy at University Hospital of Bratislava were identified in the period from January 1st 2008 to December 31th 2013. Included were only those cases which had a histological evidence of placenta accreta. RESULTS: Fifty patients, who underwent peripartum hysterectomy were included in the study. Between 2008 and 2013 eight cases of placenta accreta were identified. Five (62.5 %) of these were suspected before delivery. The overall incidence of PA was 0.19 per 1000 deliveries. Median gestational age at delivery was 37 weeks (range 25-41 weeks). Six of eight (75 %) women with placenta accreta had a previous caesarean delivery or curettage. In 5 patients both placenta praevia and prior Caesarean delivery were present. Among the 50 women who underwent peripartum hysterectomy, 8 (16 %) were patients with both prenatally diagnosed placenta praevia and previous caesarean delivery, placenta accreta was suspected in 4 of these (50 %) compared with 10 of 42 (24 %) without this combination of risk factors. CONCLUSIONS: Those in whom placenta accreta was suspected were delivered earlier than 37 weeks of gestation and were less likely to have emergency delivery. Placenta accreta is the second most common indication for an emergency peripartum hysterectomy. There is a high suspicion of placenta accreta in patients with placenta praevia and after previous Caesarean section (Tab. 3, Ref. 17).

[Evolution of peripartal hysterectomy at our department - five years evaluations]. / Vývoj peripartálnej hysterektómiena nasom pracovisku - pätrocná stúdia.

The purpose of this study was to determine the frequency, indications, complications and risk factors associated with peripartum hysterectomy carried out at our clinical department between 1st January 2008 and 31th December 2012. Peripartum hysterectomy was defined as a hysterectomy performed less than 48 hours after delivery. Clinical characteristic and obstetric histories were retrospectively reviewed between 5 years. There were 20 emergency peripartum hysterectomies among 13 660 deliveries at our department. The overall rate of peripartum hysterectomy was 1,46 per 1000 deliveries. The primary indications for hysterectomy were uncontrolled bleeding caused by uterine hypotony (45%), followed by placenta praevia (25%). Other indications were placental abruption (15%), pelvic endometriosis (5%), placenta increta (5%) and uterus myomatosus (5 %). The incidence of peripartum hysterectomy increased 2-fold in cases of placental patology, and 17-fold in cases of uterine hypotony. Overall, 95% of hysterectomy patients required transfusions.

[Thrombotic microangiopathy in pregnancy complicated by acute hemorrhagic-necrotic pancreatitis during early puerperium]. / Trombotická mikroangiopatia v gravidite komplikovaná akútnou hemoragicko-nekrotickou pankreatitídou vo vcasnom sestonedelí

OBJECTIVE: Authors in the article describe a case of a patient with thrombotic thrombocytopenic purpurain 37 weeks gestation complicated by acute severe hemorrhagic-necrotic pancreatitis during the early puerperium. DESIGN: Case report. SETTING: Ist Department of gynaecology and obstetrics of the Comenius University Bratislava. CASE-REPORT: 33-years-old patient in the 37 weeks gestation was admitted to our department with the signs of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). Due to the worsening clinical status, we have performed caesarean section. After the transient stabilization of the patient's clinical status, the hemolysis with severe thrombocytopenia reappeared. Based on the clinical signs of abdominal pain and computer tomography, the diagnosis of acute hemorrhagic-necrotic pancreatitis was set. The primary diagnosis was thrombotic thrombocytopenic purpura. Therefore, therapeutic plasma exchange was performed with consequent improvement of the patients clinical state. Normalization of the platelet count was achieved after 4.plasma exchanges. Consequently 5 plasma exchanges were performed. However, one month later, the disease relapsed. Therapeutic plasma exchanges were needed again (4x), with anti CD 20 administration. This therapy had good clinical outcome, without the need for further plasma exchanges. CONCLUSION: Thrombotic thrombocytopenic purpura is highly lethal disease. Early diagnosis, treatment, and multidisciplinary approach are essential.

Longitudinal evaluation of markers of hemostasis in pregnancy.

OBJECTIVE: The aim of this study was to establish the physiologic changes in hemostasis during pregnancy and to find the association between the factor V Leiden mutation and adverse pregnancy outcome. METHODS: We investigated blood samples of 148 pregnant women during each trimester of pregnancy. We measured their serum concentrations of factors I, II, V, VII, VIII, IX, X, XI, XII, D-dimers, prothrombin time, INR, aPTT, activity of protein C and S, antithrombin III and platelet count. The pregnancy outcome of women with factor V Leiden mutation was compared to those without congenital thrombophilia. RESULTS: Prothrombin time, INR and aPTT were significantly shorter. We found significantly higher plasma concentrations of fibrinogen and d-dimers and higher levels of activity of factor VII and X in the third trimester. No significant difference was found in protein C and antithrombin III activity. The protein S activity was lower in the second trimester and it increased in the third trimester. Although most of the clotting factors were rising during the pregnancy, there was no evidence of fibrinolytic overactivation. In our study, the carriership of factor V Leiden mutation did not affect the incidence of preeclampsia, eclampsia, intrauterine fetal death and venous thromboembolism. Placental abruption was rare. CONCLUSION: Hemostatic changes in pregnancy are significant and essential, and have the potential to cause adverse pregnancy outcome. In addition, hypercoagulable state during pregnancy is considered to be physiological (Tab. 4, Ref. 36).

Factor V Leiden mutation and its impact on pregnancy complications.

OBJECTIVE: The aim of this prospective study was to find the association between the factor V Leiden mutation and adverse pregnancy outcomes. METHODS: This study is an analysis of a prospective observational study of the frequency of placenta-mediated complications of factor V Leiden mutation carriers. We compared pregnancy outcomes of 11 women with a heterozygous form of the factor V Leiden mutation with 41 women of a control group. RESULTS: All pregnancies ended with delivery of a living infant. None of the 52 pregnancies were complicated by venous thromboembolism. There were a few significant differences regarding placenta-mediated complications. The gestational age at delivery showed small significant differences. There was a significant difference in the birth weight deviation in percentage between FVL carriers and controls. The incidence of blood loss exceeding 1000 ml was higher in the control group. CONCLUSIONS: Carriership of the factor V Leiden mutation did not affect the incidence of preeclampsia. Adverse pregnancy outcomes such as placental abruption were rare. Eclampsia, intrauterine fetal death and venous thromboembolism did not occur. Our results provide evidence that the maternal heterozygous FVL mutation did not increase the risk of an adverse pregnancy outcome.