Successful medical treatment with octreotide for chyloperitoneum following paraaortic lymphadenectomy in the treatment of gynecologic malignancies: a report of 2 cases.

BACKGROUND: Chyloperitoneum is a rare and challenging complication following systematic pelvic and retroperitoneal lymphadenectomy in the management of gynecologic malignancies. Despite its infrequent occurrence, postoperative chyloperitoneum is associated with significant morbidity. CASES: Two patients developed chyloperitoneum following paraaortic lymphadenectomy for ovarian carcinoma and endometrial carcinoma, respectively. In both cases early infusion of octreotide, a somatostatin analogue, resulted in rapid resolution of chyloperitoneum. There was no evidence of ascites at 6 and 10 months' follow-up, respectively. CONCLUSION: It is suggested that the early administration of octreotide in the course of chyloperitoneum following paraaortic lymphadenectomy in the treatment of gynecologic malignancies is highly effective and should be initiated early in the course of treatment before any invasive options are considered.

Acute urinary retention caused by endometrial carcinoma with large cystic cervix.

INTRODUCTION: Several pelvic masses have been known to cause urinary retention due to a mass effect with the bladder being obstructed secondary to compression of the urethra or bladder neck. MATERIALS AND METHODS: We report the extremely rare case of endometrial carcinoma with an enlarged cystic cervix which resulted in acute urinary retention. A 92-year-old woman was referred for acute urinary retention. Vaginal ultrasound revealed a 70 × 70 × 65 cm-sized cystic lesion in the cervix. Voiding became normal immediately after the incision and drainage of the mass. Ultrasound performed after the incision revealed a hyperechogenic mass with a honeycomb appearance in the uterine cavity. Endometrial biopsy revealed well-differentiated adenocarcinoma of the endometrium. Total hysterectomy and bilateral salpingo-oophorectomy was performed. CONCLUSION: The possible existence of endometrial carcinoma should be considered when the enlargement of cervix is clinically suspected in an elderly woman even if there is no vaginal discharge or bleeding.

Obstetric risk factors associated with the development of periventricular leukomalacia in preterm infants born to mothers complicated by placenta previa.

OBJECTIVES: This study was designed to evaluate the effect of antenatal risk factors on the occurrence of periventricular leukomalacia (PVL) in preterm infants from pregnancies complicated by placenta previa. STUDY DESIGN: The association between obstetric risk factors and PVL was assessed in 30 singleton live births complicated with placenta previa delivered between 24 and 33 completed weeks of gestation. Each infant underwent at least two cranial ultrasounds: the first before 72 h and the second around 14 days of life. Analysis of variance was used to compare continuous variables across groups. Comparison of groups for categorical data was analyzed with Pearson chi(2) test. RESULTS: The obstetric factors in infants with PVL were compared to those in infants with negative cranial ultrasonographic findings. The main risk factors for PVL in preterm placenta previa were initial antepartum hemorrhage <28 weeks of gestation (OR 13.7; 95% CI 1.38-136.2), although the differences of gestational age of delivery between two groups were not statistically significant. Low Apgar score (<7) at 1 min increased the risk of PVL (OR 8.89; 95% CI 12.9-61.1), while no associations with PVL were observed in low Apgar score at 5 min, neonatal acidosis (pH <7.2), and neonatal anemia (Hb <14 g/dl). CONCLUSIONS: This study demonstrates that initial antepartum hemorrhage during the second trimester and low Apgar score at birth increase the risk of PVL in preterm infants born to mothers with placenta previa. We speculate that the pathophysiologic mechanisms for this finding may be due to decreased placental perfusion in the second trimester of pregnancy, which is the developmental window of vulnerability for PVL.

Pregnancy outcome of uterine arterial embolization followed by selective hysteroscopic removal of a placental polyp.

OBJECTIVE: To evaluate the pregnancy outcome of uterine arterial embolization followed by selective hysteroscopic removal of a placental polyp. METHODS: Thirteen patients of placental polyp with abundant blood flow, which was diagnosed by ultrasound with color Doppler imaging, were studied. They underwent uterine arterial embolization followed by selective hysteroscopic removal of the polyp. Uterine arterial embolization was carried out using an absorbable gelatin sponge. Selective removal via hysteroscopy was performed on the following day, using the cutting loop with or without electrical stimulation. The polyp was gradually resected to the level of the surrounding endometrium. RESULTS: Complete removal of the placental polyp was achieved in all patients. The presence of placental polyp was confirmed by pathologic examination. The operative time ranged from 20 to 53 min. In all cases, no complications were noted and the bleeding was minimal during and immediately after the procedure. Postoperative ultrasound demonstrated a uterine cavity free of residual mass in each case. The seven patients with complete gestation gave birth to health babies. No recurrence of placental polyp was observed. CONCLUSIONS: Selective removal directed via hysteroscopy after reduction of blood supply by uterine arterial embolization provides a safe and effective method to minimize bleeding, and can preserve future fertility and successful uneventful pregnancies in the treatment of placental polyp with abundant blood flow.

Prevention of postpartum hemorrhage by uterotonic agents: comparison of oxytocin and methylergometrine in the management of the third stage of labor.

OBJECTIVES: To determine the efficacy of intravenous oxytocin administration compared with intravenous methylergometrine administration for the prevention of postpartum hemorrhage (PPH), and the significance of administration at the end of the second stage of labor compared with that after the third stage. METHODS: A prospective study was undertaken: two major groups (oxytocin group and methylergometrine group) of 438 women with singleton pregnancy and vaginal delivery were studied during a 15-month period. These two groups were subdivided into three subgroups: 1. intravenous injection (two minutes) group immediately after the delivery of the fetal anterior shoulder, 2. intravenous injection (two minutes) group immediately after the delivery of the placenta, and 3. drip infusion (20 min) group immediately after the delivery of the fetal head. In each group, quantitative postpartum blood loss, frequencies of blood loss >500 ml, and need of additional uterotonic treatment were evaluated. RESULTS: As compared with methylergometrine, oxytocin administration was associated with a significant reduction in postpartum blood loss and in frequency of blood loss >500 ml. The risk of PPH was significantly reduced with intravenous injection of oxytocin after delivery of the fetal anterior shoulder, compared with intravenous injection of oxytocin after expulsion of the placenta (OR 0.33, 95%CI 0.11-0.98) and intravenous injection of methylergometrine after delivery of the fetal anterior shoulder (OR 0.31, 95%CI 0.11-0.85). CONCLUSIONS: Intravenous injection of 5 IU oxytocin immediately after delivery of fetal anterior shoulder is the treatment of choice for prevention of PPH in patients with natural course of labor.

A case of virilizing brenner tumor in a postmenopausal woman with stromal androgenic activity.

Although there are several reports of Brenner tumor showing estrogen activities, it is an extremely rare cause of androgen excess leading to virilism, and the source or mechanism of its androgen production is also unknown at present. A 74-year-old woman presented with lower abdominal pain and increased facial hair growth of 6-month duration. Bilateral ovarian tumors were detected, and her serum testosterone (1.7 ng/mL) and estradiol (75 pg/mL) levels were elevated. Bilateral salpingo-oophorectomy was performed. The ovarian tumors were diagnosed as benign Brenner tumor associated with fibrothecoma-like and luteinized stromal cells. Postoperatively, the serum testosterone and estradiol levels decreased. Immunohistochemically, fibrothecoma-like stromal cells were positive for cytochrome P-450 aromatase, which catalyzes the conversion from androgen to estrogen, and negative for c-Jun protein, which has recently reported to attenuate estrogen biosynthesis by directly down-regulating transcription of the aromatase gene. On the other hand, luteinized stromal cells were negative for cytochrome P-450 aromatase and positive for c-Jun protein. It is suggested that androgen is produced mainly in the luteinized stromal cells, because androgen is not converted to estrogen caused by suppression of aromatase biosynthesis by c-Jun.

Effects of combined estriol/pravastatin therapy on intima-media thickness of common carotid artery in hyperlipidemic postmenopausal women.

BACKGROUND: Several studies show that 17beta-estradiol (E2) has protective effects on atherosclerosis in the arterial wall in postmenopausal women. Little information is, however, available regarding the effect of estriol (E3) on atherosclerosis. This study was conducted to investigate the effects of E3 alone and combined E3/pravastatin therapy on intima-media thickness (IMT) of common carotid artery in postmenopausal women. METHODS: Thirty-three postmenopausal women were allocated to four groups: daily treatment with E3 (2 mg) alone (E3 group, n = 10), pravastatin (10 mg) alone (pravastatin group, n = 6), combined treatment with E3 (2 mg) and pravastatin (10 mg; E3/pravastatin group, n = 7) and untreated control group (n = 10). All women attended the Kobe University Hospital once a year for routine gynecological and ultrasonographic examinations for the evaluation of atherosclerosis. RESULTS: A significant decrease in IMT was noted in the E3/pravastatin group compared with that in the untreated control group (p < 0.05), whereas there was no significant difference in the reduction rate of IMT in the pravastatin group, E3 group and untreated control group. CONCLUSIONS: The combined E3/pravastatin therapy appeared to retard the progression of atherosclerosis in postmenopausal women.

Peritonitis caused by a ruptured, infected mesenteric cyst initially interpreted as an ovarian cyst. A case report.

BACKGROUND: Mesenteric cysts are rare intraabdominal lesions of childhood that may vary in presentation from an asymptomatic mass to an acute abdomen. CASE: We encountered a rare case of peritonitis caused by a ruptured, infected mesenteric cyst of the mesocolon in a female child that had been initially interpreted as a ruptured ovarian cyst. CONCLUSION: When confronted with a large unilocular or septated echolucent mass in the lower abdomen in female children, gynecologists should consider a mesenteric cyst in the differential diagnosis.

Successful medical treatment with danazol after failed embolization of uterine arteriovenous malformation.

BACKGROUND: Transcatheter arterial embolization has been the therapy of choice for uterine arteriovenous malformations, whereas medical therapy has not been popular because of patient propensity to bleed. CASE: A 29-year-old woman, gravida 3, para 0, was diagnosed with uterine arteriovenous malformation. Because initial treatment with uterine artery embolization was unsuccessful, she was ultimately treated with danazol. Resolution of the lesion after 2 weeks of danazol therapy was observed. As of follow-up at 16 months, she has remained free from further abnormal bleeding episodes and recurrence of the lesion. CONCLUSION: Danazol has the potential for medical management of uterine arteriovenous malformations in hemodynamically stable patients who do not respond to embolization.

Comparison of magnetic resonance imaging and ultrasonography in the prenatal diagnosis of congenital thoracic abnormalities.

OBJECTIVES: To evaluate prenatal MRI in the diagnosis of fetal thoracic abnormalities and to determine whether MRI provides useful information in addition to that of ultrasonography (US). METHODS: Ultrafast MR scanning was performed in 7 pregnant women in whom US was suspicious of fetal congenital anomalies of the thorax [3 cases of congenital diaphragmatic hernia (CDH), 3 cases of chylothorax and 1 case of congenital cystic adenomatoid malformation (CCAM) type III]. The presence, position, size and characteristics of the congenital lesions were determined and compared with postnatal diagnoses. RESULTS: The MRI diagnoses were 3 cases of CDH, 2 of chylothorax and one each of esophageal atresia and CCAM type III. The results of MRI were in agreement with those of US in 6 cases and in disagreement in 1 case of esophageal atresia. Final diagnoses were confirmed at surgery or autopsy in all fetuses. Combined use of MR and US imaging enabled a correct diagnosis in 5 cases and led to an error in the diagnosis of 1 fetus with bronchial stenosis, which had been diagnosed as CCAM type III by US and MRI. MRI led to a correct diagnosis in 1 fetus with esophageal atresia, in whom US had been equivocal in the prenatal diagnosis. CONCLUSION: MRI helped further characterize the fetal thoracic lesions and confirmed or changed the prenatal diagnosis based on US. MRI seems to be powerful in the prenatal diagnosis of thoracic lesions that are atypical or complicated by multiple abnormalities.

Bioelectrical impedance analysis in the clinical management of preeclamptic women with edema.

OBJECTIVE: The aim of this study was to correlate bioelectrical impedance analysis (BIA) with the clinical course of preeclampsia with edema. DESIGN: 440 pregnant women with apparently normal, single pregnancy participated in this longitudinal study. Anthropometric measurements and BIA were performed during pregnancy and postpartum period. RESULTS: All of the measurements were completed in 333 of the women; 279 of the women had a normal pregnancy (control group). The remaining 54 women developed edema during the third trimester of pregnancy. Of these, 40 women had only edema, and 14 women had edema followed by hypertension and/or proteinuria (preeclampsia group). The BIA index (the height squared divided by resistance) in the control group increased significantly towards late pregnancy, compared to that in early pregnancy. The indexes in the edema group were significantly higher during the third trimester compared to those of the control group at the same gestational week. The index in the preeclampsia group was higher relative to that in the control group. Moreover, a substantial increase in the index preceded the development of edema in the cases in which pregnancy was terminated due to deterioration of preeclampsia. CONCLUSIONS: Our results show that BIA is a useful method for monitoring longitudinal changes in total body water in pregnant women, and that BIA may be a powerful predictor of deterioration of preeclampsia preceded by edema.

Prenatal imaging of congenital cerebral primitive neuroectodermal tumor.

A case of fetal brain tumor, which appeared after 32 weeks' gestation, is presented. Prenatal ultrasonography and magnetic resonance imaging demonstrated a large heterogeneous mass in the right supratentorial region and left enlarged ventricle. A male fetus weighing 2,616 g was delivered at 34 weeks' gestation by cesarean section and died on the 37th day of life due to rapid growth of the tumor. Following autopsy, the pathohistological examination revealed primitive neuroectodermal tumor. Magnetic resonance imaging in the prenatal management of the congenital brain tumor is efficient in evaluating the expansion and margin of the tumor and intratumoral bleeding, which are not demonstrated by ultrasonography.

Prenatal evaluation of bidirectional epignathus: comparison of ultrasonography and magnetic resonance imaging.

Epignathus is an unusual, benign, congenital teratoma of the hard palate. Most of these teratomas are unidirectional and protrude through the mouth. Hence, the prognosis depends on the size of the tumor and degree of face distortion and airway obstruction. Occasionally, intracranial extension of the tumor is present, involving and destroying the brain tissue, resulting in a poor prognosis. The authors describe 2 cases of bidirectional epignathus, showing the different findings on ultrasonography and magnetic resonance imaging.

Selective transarterial embolization and hysteroscopic removal of a placental polyp with preservation of reproductive capacity.

OBJECTIVE: To evaluate the role of transarterial embolization followed by hysteroscopic removal of a placental polyp with preservation of reproductive capacity. STUDY DESIGN: Three patients with placental polyps with abundant blood flow, suspected on ultrasonography with color Doppler imaging and on magnetic resonance imaging, were studied. They underwent transarterial embolization followed by hysteroscopic removal of the polyp. Transarterial embolization of the bilateral uterine arteries was carried out using an absorbable gelatin sponge. Selective removal via hysteroscopy was performed on the following day using a cutting loop without electrical stimulation. The polyp was gradually resected to the level of the surrounding endometrium. RESULTS: Complete removal of the placental polyp was achieved in all patients. The presence of a placental polyp was confirmed by pathologic examination. The operative time was ranged from 26 to 53 minutes. In all cases, no complications were noted, and bleeding was minimal during and immediately after the procedure. Postoperative ultrasonography demonstrated a uterine cavity free of residual mass in each case. CONCLUSION: Transarterial embolization of the uterine arteries followed by selective hysteroscopic removal is a safe and effective method of minimizing bleeding and preserves fertility in the treatment of placental polyps with an abundant blood flow.

Transient postpartum diabetes insipidus in twin pregnancy associated with HELLP syndrome.

Diabetes insipidus during pregnancy is an uncommon medical problem, and its cause is not entirely clear. We present a woman with twin pregnancy associated with HELLP syndrome, who developed diabetes insipidus during postpartum period. A hypertonic saline infusion study with measurement of plasma arginine vasopressin concentrations confirmed the diagnosis. She had mild response to 1-desamino-8-d-arginine-vasopressin (dDAVP) during the immediate postpartum period. On the 3rd postpartum day two doses of 100 microliters of dDAVP were administered, and her urinary volume gradually decreased. We could stop dDAVP on the 30th postpartum day. This exacerbation may result from increased vasopressinase activity caused by the excessive production in the placenta due to twin pregnancy, together with the insufficient degradation in the liver due to HELLP syndrome.