An analysis of HELLP syndrome cases: does platelet count predict adverse maternal and fetal outcomes in women with HELLP syndrome?

PURPOSE: To evaluate the maternal and fetal outcome in 44 pregnancies complicated with HELLP syndrome and to investigate the role of platelet counts in its prognosis. METHODS: A retrospective analysis of the medical records of 44 patients with the diagnosis of hemolysis elevated liver enzymes and low platelet count between June 1997 and January 2009 was performed. The patients were divided into two groups according to blood platelet count: platelet count <50,000 mm(3) formed Group I and platelet count 50,000-100,000 mm(3) formed Group II. Clinical findings and laboratory characteristics, maternal complications, perinatal outcomes and comparison of maternal and fetal morbidity according to platelet counts were analyzed. RESULTS: During the period of 12 years, 44 (0.54%) of 8,132 deliveries had HELLP syndrome. Among 44 patients, the most common complications were disseminated intravascular coagulopathy (18.2%), acute renal failure (15.9%), abruptio placentae (11.4%), and cerebral hemorrhage/infarction (11.4%). Maternal and perinatal mortality rates in HELLP syndrome were 9.1 and 40.9%, respectively. Aspartate aminotransferase levels were found to be statistically significantly higher in Group I (p = 0.04). While disseminated intravascular coagulopathy and acute renal failure were statistically significantly higher in Group I (p = 0.01; p = 0.03 respectively), fetal growth restriction was statistically significantly higher in Group II (p = 0.04). CONCLUSIONS: HELLP syndrome is associated with high incidences of maternal and fetal morbidity and mortality and patients with low platelet counts might have a much increased risk.

Intracranial injection with KCl: an alternative method in selected cases of multifetal pregnancy reduction.

Multifetal pregnancy reduction (MFPR) offers a therapeutic option which reduces the maternal, prenatal, neonatal morbidity and mortality associated with multifetal pregnancies. In certain cases of MFPR, where difficulty is encountered in reaching the thorax due to the fetal position as well as the location of membranes and placenta, an alternative approach may be the insertion of the needle to the fetal cranium. We describe a new technique for MFPR performed by fetal intracranial injection of potassium chloride. To our knowledge, the current case series is the first report describing the technique of intracranial injection of potassium chloride during MFPR and selective termination. This approach enables a technically easier procedure than the intrathoracic approach. However, the use of this technique should be reserved for selected cases of MFPR only by experienced operators and centers.

Laparoscopic management of heterotopic cesarean scar pregnancy with preservation of intrauterine gestation and delivery at term: case report.

OBJECTIVE: To present a case of laparoscopic removal of a heterotopic cesarean scar pregnancy under ultrasound guidance. DESIGN: Case report. SETTING: Private hospital. PATIENT(S): A 34-year-old woman with heterotopic cesarean scar pregnancy. INTERVENTION(S): Laparoscopic removal of heterotopic cesarean scar pregnancy. MAIN OUTCOME MEASURE(S): Delivery at term after laparoscopic management of heterotopic cesarean scar pregnancy. RESULT(S): An ongoing intrauterine pregnancy ended with a live birth after successful removal of the heterotopic gestational mass by a laparoscopic approach. CONCLUSION(S): Surgical removal of the ectopic mass by laparoscopy may be a radical approach in cases of heterotopic cesarean scar pregnancy. Laparoscopic excision of the cesarean scar pregnancy gives the opportunity to preserve the viable intrauterine gestation while maintaining a strong lower uterine segment. Ultrasound is an adjunctive tool that enables precise location of the ectopic mass during the operation.

Cranial thromboembolism secondary to patent foramen ovale and deep venous thrombosis after cesarean section.

BACKGROUND: Paradoxical embolism via a patent foramen ovale (PFO) is a rare event in the puerperium as a cause of stroke. CASE: We report a 21-year-old, G4P3A1 woman with the symptoms of convulsion, stroke and unconsciousness 1 week after cesarean delivery. An infarction was detected in both frontal lobes, and echocardiography and MRI confirmed the PFO. Her follow-up course with low-molecular-weight heparin and then warfarin for 6 months was uneventful. CONCLUSION: Patients with an unexplained arterial event should be screened for PFO and possible paradoxical embolism.

Spontaneous vaginal expulsion of an infected necrotic cervical fibroid through a cervical fistula after uterine artery embolization: a case report.

BACKGROUND: Uterine artery embolization (UAE) is promising, minimally invasive therapy being offered to women for treatment of fibroids. Although it seems to be safe and effective, major complications and adverse outcomes have been reported. CASE: A patient treated with UAE for a huge cervical fibroid presented with an infected, necrotic cervical mass lesion 4 weeks after the procedure. Spontaneous vaginal expulsion of the infected cervical fibroid from the left lateral cervical fistula tract occurred 3 weeks later while the patient was receiving antibiotic therapy. After 6 months of intervention, an approximately 99% regression rate in the fibroid volume was achieved. The patient gave birth to a healthy, female infant following a spontaneous, uneventful pregnancy and vaginal delivery. CONCLUSION: UAE appears to be associated with a significant reduction in fibroid volume. Expulsion of the infected, necrotic parts of the fibroid after UAE may be accepted as a natural process. Warning the patient about this potential risk, early recognition of infective complications and lose follow up seem to be crucial to avoiding potentially fatal septic shock.

Color Doppler sonographic analysis of uterine and ovarian artery blood flow in women with polycystic ovary syndrome.

PURPOSE: To study the blood flow patterns of utero-ovarian circulation in polycystic ovary syndrome (PCOS) and to assess their relationship with clinical, metabolic, and hormonal data. METHODS: Forty-three women with PCOS and 43 age-matched healthy controls underwent Doppler examination of the utero-ovarian circulation in the follicular phase. Demographic, hormonal, and metabolic parameters were determined. Student's t-test, chi(2)-test, and Spearman correlation test were used for statistical analysis. RESULTS: The ovarian artery pulsatility index (PI), resistance index (RI), and SD ratios were significantly lower in PCOS than in controls on the right side (p < 0.001, p = 0.02, p = 0.001, respectively) as well as on the left side (p < 0.001, p < 0.001, p < 0.001, respectively). The uterine artery systolic/diastolic (S/D) ratio was higher on both sides (p = 0.01) and the PI was higher on the left side (p = 0.02) in PCOS than in controls. The right uterine artery PI was positively correlated with luteinizing hormone and hemoglobin (r = 0.417, p = 0.043; r = 0.427, p = 0.033, respectively), the right uterine artery S/D was positively correlated with body mass index (r = 0.479, p = 0.015), and the left uterine artery PI was positively correlated with insulin (r = 0.458, p = 0.021). CONCLUSION: Doppler sonography of the utero-ovarian circulation may contribute to the evaluation of PCOS patients and a better understanding of the pathophysiology of this syndrome.

Is prostate-specific antigen a potential new marker of androgen excess in polycystic ovary syndrome?

AIM: To determine whether serum prostate-specific antigen (PSA) levels are increased in polycystic ovary syndrome (PCOS) and the possibility of PSA to be used as a diagnostic marker of hyperandrogenism in females. METHODS: A total of 43 women with PCOS and 43 age-matched healthy females were recruited in this prospective case-control study. The subjects were compared by means of demographic parameters, hormonal and metabolic measures and serum PSA levels. The correlations between this marker and a wide variety of hormonal, biochemical, anthropometric measures were evaluated. Student's t-test, chi2-test and Spearman's correlation analysis were used for the statistical analysis where appropriate. Statistical significance was assumed with a value of P<0.05. RESULTS: Mean body mass index, waist/hip ratio, Ferriman-Gallwey scores (FG), lutenizing hormone/follicle stimulating hormone ratio, insulin resistance, serum triglycerides and very low density lipoprotein levels were demonstrated to be significantly higher in PCOS (P=0.02, P=0.008, P

Gastric carcinoma diagnosed at the third trimester: a case report.

Gastric carcinoma associated with pregnancy appears to be an extremely rare entity. It is usually diagnosed at advanced stages of the disease and presents a grave prognosis. Since the fatal outcome shows a rapid course within months of diagnosis, prompt gastroduodenal endoscopic examination following early clinical suspicion is mandatory. A case of 29 year-old pregnant woman with 31 weeks of gestation is herein presented. The women was diagnosed as gastric adenocarcinoma while being investigated for intractable nausea, vomiting, and a concomitant epigastric mass. She underwent radical gastric resection and received six cycles of adjuvant chemotherapy following vaginal delivery of a healthy 1950 g fetus. The patient was dead 20 weeks after the surgery due to pulmonary and hepatic metastasis.

Maternal and perinatal outcome in pregnancies complicated with hypertensive disorder of pregnancy: a seven year experience of a tertiary care center.

OBJECTIVE: The aim of the study was to determine the risk factors, prevalance, epidemiological parameters and maternal-perinatal outcome in pregnant women with hypertensive disorder. MATERIALS AND METHODS: A retrospective analysis was undertaken on 255 consecutive cases of hypertensive disorder in pregnancy who were managed at Kocaeli University, School of Medicine, Department of Obstetrics and Gynecology from June 1997 to November 2004. Demographic data involving age, parity, gestational week, clinical and laboratory findings were recorded from the medical files. Additionally delivery route, indications of cesarean section, fetal and maternal complications were determined. Statistical analysis was performed by SPSS programme using Kruskal Wallis nonparametric test, ANOVA (Analysis of variance) and chi-square tests. RESULTS: Of 5,155 deliveries in our clinic during the defined period, 438 cases (8.49%) were managed as hypertensive disorder of pregnancy. Medical records of 255 cases could be avaliable. Of 255 cases, 138 patients (54.11%) were found to have severe preeclampsia while 88 cases (34.50%) were diagnosed as mild preeclampsia. Twenty-nine patients (11.37%) were suffering from chronic hypertension. Of 138 severely preeclamptic cases, 28 cases (11%) had eclamptic convulsion and another 28 patients (11%) were demonstrated to have HELLP syndrome. Intrauterine growth restriction, oligohydramnios, placental ablation were the obstetric complications in 75 (29.4%), 49 (19.2%), 19 (7.5%) cases, respectively. Additionally multiple pregnancy and gestational diabetes mellitus were noted in 5.9% (n:15) and 3.9% (n:10) of the patients. Delivery route was vaginal in 105 patients (41.2%) while 150 patients (58.8%) underwent cesarean section with the most frequent indication to be fetal distress in 69 cases (46%). Cesarean section rate seemed to be the lowest (48.3%) in chronic hypertensive women while the highest (63.8%) in severe preeclamptic patients. Maternal mortality occured in 3 cases (1.2%) and all of those cases were complicated with HELLP syndrome. Intracranial bleeding was the cause of maternal death in one case while the other two cases were lost due to acute renal failure and disseminated intravascular coagulation, respectively. Intrauterine fetal demise was recorded in 24 cases on admission. Ten fetuses died during the intrapartum period. Mean gestational age and birth weight were 28 +/- 3.5 and 1000 +/- 416 g, respectively in this group. In these ten women, five cases were diagnosed as HELLP syndrome, two were severely preeclamptic and three were eclamptic. Perinatal mortality rate was found to be 144/1,000 births CONCLUSION: Hypertensive disorder of pregnancy is associated with increased risk of maternal-perinatal adverse outcome. The complications of severe preeclampsia and eclampsia could be prevented by more widespread use of prenatal care, education of primary medical care personnel, prompt diagnosis of high-risk patients and timely referral to tertiary medical centers.

Misoprostol 50 microg sublingually versus vaginally for labor induction at term: a randomized study.

OBJECTIVE: To compare the efficacy of misoprostol 50 mug vaginally and 50 mug sublingually for labor induction at term. MATERIALS AND METHODS: One hundred and sixty women were randomized to receive misoprostol 50 microg vaginally (n = 80) or 50 microg sublingually misoprostol (n = 80). The doses were given every 4 h (maximum 6 doses). Primary outcome measure was number of cesarean deliveries. Induction to delivery time, delivery within 24 h, the number of misoprostol doses given; the need for oxytocin augmentation, tachysystole and uterine hyperstimulation rates and neonatal outcomes were secondary outcome measures. RESULTS: The mean induction to delivery time was 748 +/- 379 min in the vaginal group and 711 +/- 425 in the sublingual group (p = 0.56). The number of women delivering within 24 h was 73 (91.3%) in the vaginal group and 74 (92.5%) in the sublingual group (p = 0.78). The mean number of misoprostol doses required was significantly higher in the sublingual group (1.9 +/- 1.2) compared with the vaginal group (1.1 +/- 0.4; p < 0.001). More women in the sublingual group experienced tachysystole (n = 14, 17.5%) compared with the vaginal group (n = 3, 3.8%; p = 0.005). Seven cases (8.8%) in the vaginal group and 12 cases in the sublingual group (15%) required emergent cesarean delivery for fetal heart rate abnormalities (p = 0.22). Other neonatal outcomes including umbilical artery pH, Apgar scores and intensive care unit admission were similar in the two groups. CONCLUSION: Sublingual misoprostol is as efficacious as vaginal misoprostol for induction of labor. More frequent tachysystole is observed with misoprostol 50 microg sublingually, but neonatal outcomes are similar.