Spontaneous uterine rupture in the early third trimester after laparoscopically assisted myomectomy. A case report.

BACKGROUND: The development of new and innovative laparoscopic instruments has allowed a greater number of gynecologic surgeons to laparoscopically remove large, intramural leiomyomata. Cases of both successful pregnancy and uterine rupture following laparoscopic myomectomy have been reported. This is the first report of uterine rupture in pregnancy following a laparoscopically assisted myomectomy. CASE: A 26-year-old, nulligravid woman underwent a laparoscopically assisted myomectomy. While the myomectomy had been performed laparoscopically, the uterine incision had been repaired in layers through a minilaparotomy incision. Two years later she became pregnant and, at 29 weeks' gestation, presented to labor and delivery with contractions and uterine tenderness. Over the next several hours, a nonreassuring fetal heart rate developed, and a cesarean section was performed, revealing hemoperitoneum and uterine rupture at the site of the prior myomectomy. CONCLUSION: The ultimate integrity of a uterine incision may depend not only on how the incision is repaired but also on how it is made. Laparoscopically created uterine incisions may not be as strong as those made at laparotomy, regardless of the method of closure.

Thiamin status of gravidas treated for gestational diabetes mellitus compared to their neonates at parturition.

Since thiamin plays a role in glucose metabolism we wanted to know if blood thiamin influx from gravida to neonate was influenced by treatment of gravidas having gestational diabetes mellitus (GDM). In this study we found thiamin hypovitaminemia in 19% of the 77 pregnancies despite vitamin supplementation and treatment for GDM; neonates born to mothers with hypovitaminemia were also thiamin hypovitaminemic. All neonatal blood had significantly higher thiamin concentration than gravidas. Indeed, cord blood from neonates born to mothers treated with insulin for GDM had significantly higher thiamin concentration than other neonates in the study. A significant weight depression was noted in neonates born to treated GDM mothers. Healthy gravidas giving birth to macrosomia neonates, had significant thiamin hypovitaminosis, but only macrosomic neonates of treated diabetic mothers had significantly depressed blood thiamin concentrations. We noted that subclinical thiamin hypovitaminemia is prominent during pregnancy despite vitamin supplementation. Perhaps increased thiamin supplementation during pregnancy seems warranted to avoid metabolic stress in mother and fetus due to thiamin hypovitaminemia.

Factors associated with maternal cell contamination in amniocentesis samples as evaluated by fluorescent in situ hybridization.

OBJECTIVE: To determine which patient- and procedure-related factors contribute to maternal cell contamination in uncultured amniocentesis fluid. METHODS: One hundred thirty amniotic fluid (AF) samples were obtained by three operator groups: maternal-fetal medicine faculty (n=50), general obstetrician gynecologists (n=50), and obstetrics and gynecology residents supervised by maternal-fetal medicine faculty (n=30). These groups were designated "most," "intermediate," and "least experience," respectively. Study variables were recorded at the time of the procedure. Amniotic fluid cells from male fetuses underwent fluorescent in situ hybridization. Maternal cell contamination was calculated by analyzing 100 cells and determining the number of XX and XY cells. A control system was created to validate the methods used for AF processing and cell counting. RESULTS: Median maternal cell contamination was 2.0%. Maternal cell contamination did not vary with body mass index (r=-.13, P=.14), gestational age (r=.08, P=.35), or placental location (P=.55). Maternal cell contamination was significantly elevated with placental penetration (6.0% compared with 1.0%, P < .001), two passes (27.5% compared with 2.0%, P=.002), blood-tinged fluid color (14.0% compared with 2.0%, P < .001), and operator inexperience ("intermediate experience" compared with "most experience," 4.5% compared with 1.0%, P=.026). Maternal cell contamination did not differ between the "most experience" and "least experience" groups (1.0% compared with 2.0%, not significant). Concordance between detected and actual maternal cell contamination in the control system was extremely high (concordance coefficient=0.98, P=.008), confirming the validity of the techniques used. CONCLUSION: Our techniques of cell counting and maternal cell contamination calculation are accurate. Maternal cell contamination is increased with placental penetration, two passes, and operator inexperience. However, with expert supervision, inexperienced physicians can perform amniocentesis without an increase in maternal cell contamination.

Ovarian carcinoma initially presenting as metastatic axillary lymphadenopathy.

BACKGROUND: Ovarian carcinoma usually presents at advanced stage due to diffuse intraabdominal disease. Presenting signs and symptoms often relate to the degree of intraabdominal spread. It is rare to have distant lymph node metastases, in conjunction with minimal intraabdominal disease, at initial presentation. CASE: A 78-year-old woman was noted to have an enlarged axillary lymph node on a routine, screening mammogram. Biopsy revealed metastatic adenocarcinoma, consistent with primary breast cancer. Physical examination, diagnostic mammogram, and magnetic resonance imaging of the breasts were normal. A pelvic computed tomography scan revealed a 7-cm complex, right adnexal mass. At exploratory laparotomy, there was minimal intraabdominal tumor burden; only a 6-cm right ovarian tumor and a single 1.0-cm nodule adherent to the bladder peritoneum were found. After optimal cytoreductive surgery, she received tamoxifen for presumed metastatic breast cancer. One year later, recurrent disease developed in the pelvis. After reexploration and excision of all gross pelvic disease, a revised diagnosis of recurrent ovarian cancer was made, and therapy was changed to carboplatin and paclitaxel chemotherapy. The patient is currently without evidence of disease. CONCLUSION: Ovarian carcinoma usually presents with signs and symptoms related to the tumor burden within the peritoneal cavity. The finding of isolated, distant metastatic lymphadenopathy with minimal intraabdominal disease is very unusual. Immunohistochemical tumor markers can help determine the origin of a metastatic adenocarcinoma when the clinical presentation is atypical.