Puerperal inversion of one horn of a bicornuate uterus. A case report.

BACKGROUND: Acute uterine inversion is a rare (1:2,500-25,000 deliveries) but potentially life-threatening obstetric complication. Uterine malformation can make it difficult to diagnose and treat this emergency. CASE: Following a normal delivery in a nullipara, laparotomy was required to establish the diagnosis and treat an inversion of one horn of a bicornuate uterus. CONCLUSION: Inversion of one horn of a bicornuate uterus presents a diagnostic dilemma. When physical examination reveals a palpable abdominal "fundus" and a mass protruding through the cervix in a patient who is experiencing uterine hemorrhage, the cause may be inversion of one horn of a bicornuate uterus. Laparotomy may be required for definitive diagnosis and treatment.

Markedly elevated maternal serum alpha-fetoprotein associated with a normal fetus and choriocarcinoma of the placenta.

Determination of maternal serum alpha-fetoprotein (MSAFP) has become an important screening test for a variety of fetal and maternal abnormalities. A 33-year-old multiparous white woman had a markedly elevated MSAFP level (140 multiples of the median). Extensive antepartum work-up for fetal anomalies, fetal-maternal transfusion, or maternal etiology revealed no explanation. The patient subsequently delivered a healthy male infant. Pathologic examination of the placenta demonstrated a small, discrete area of choriocarcinoma. Computed tomography showed a solitary pulmonary metastasis. Because the patient did not desire future pregnancies, a total abdominal hysterectomy was performed, followed by four courses of EMA-CO chemotherapy. Her serum hCG levels subsequently became undetectable. Choriocarcinoma of the placenta must be considered in the differential diagnosis of an otherwise unexplained elevated MSAFP level.

Vaginal birth after cesarean section for arrest of labor: is success determined by maximum cervical dilatation during the prior labor?

The charts of 229 patients who attempted a vaginal birth after a cesarean section were reviewed. A total of 103 patients had a prior cesarean section for either failure to progress or cephalopelvic disproportion. On the basis of the maximum cervical dilatation in the prior labor, the patients were categorized into three groups: 0 to 5 cm, 6 to 9 cm, and 10 cm. The success rates for vaginal delivery of 61%, 80%, and 69%, respectively, were not significantly different among groups (p = 0.31). When arrest of labor was not the indication for primary cesarean section, 78% of the patients were subsequently delivered of their infants vaginally. This was not significantly different from the 70% overall success rate achieved by the group with failure to progress or cephalopelvic disproportion (p = 0.17). Similarly, when the success rate for a trial of labor was plotted against neonatal birth weight, the trends were comparable in the groups with and without failure to progress or cephalopelvic disproportion. These data suggest that patients with a prior cesarean section for arrest of labor are good candidates for a trial of labor and that the cervical dilatation previously reached does not determine the likelihood of success.

The value of curettage in the diagnosis of ectopic pregnancy.

The charts of all patients hospitalized between 1978 and 1983 with proved ectopic pregnancies at Northwestern Memorial Hospital, Chicago, and Meir Hospital, Kfar-Sava, Israel, were reviewed. Eighty-four patients with ectopic pregnancies had endometrial tissue available for histologic analyses. Review of the endometrial curettings revealed that the most common endometrium associated with ectopic pregnancy was secretory (39.4%). Proliferative endometrium present 19% of the time was as common a finding as Arias-Stella phenomenon. This study shows that any type of endometrium lacking trophoblasts may be associated with an ectopic pregnancy. The lack of decidual reaction or Arias-Stella phenomenon should not alone lower the clinician's index of suspicion.