Brain neoplasms in pregnancy. Two case histories

The diagnosis of brain tumor in a pregnant women is a dramatic event. The nature and timing of therapy at intracranial neoplasm are affected by the existence of the pregnancy. The authors report a two cases of cerebral neoplasm in pregnancy. Clinical syndromes, diagnosis, neurosurgical and obstetrical management are discussed.     

Abdominal pregnancy--report of two cases and review of literature

Ectopic pregnancy is one of the major complications of pregnancy. The abdominal pregnancy is a comparatively rare type of ectopic gestation with a high fetal and maternal morbidity and mortality. Although abdominal pregnancy had been well documented, it still remains a serious dilemma for most clinicians in the contemporary obstetric practice because of the difficulties in early diagnosis and proper management. We reported two cases of early abdominal pregnancy with accurate preoperative diagnosis followed by immediate surgical intervention and total removal of the placental tissue. The important concepts of management with this uncommon but ominous condition are discussed, including the predisposing risk factors, clinical features, diagnostic difficulties, appropriate surgery and management of the placenta.     

Paget disease of the calcaneus: findings on MR imaging

The aim of the current study was to examine whether the measurement of intrauterine human decidua-associated protein (hDP) 200 might be of clinical value in the diagnosis of ectopic pregnancy versus early missed abortion. Uterine fluid levels of hDP 200 were measured in two groups of patients: 20 women with ectopic pregnancy, diagnosed by laparoscopy, and 20 women diagnosed (after curettage) as having a missed abortion. No significant difference in hDP 200 levels was observed comparing patients with ectopic pregnancy (mean 114.0+/-58.2 mU/ml) and patients with early missed abortion (mean 222.0+/-116.0 mU/ml), although a trend towards lower levels of uterine fluid hDP 200 was noted in the group of patients presenting with tubal pregnancy. Thus, according to our data, intrauterine hDP 200 is not sufficiently discriminative to be of clinical value in the diagnosis of ectopic pregnancy.     

The accuracy of single serum progesterone measurement in the diagnosis of ectopic pregnancy: a meta-analysis

Serum progesterone measurement has been advocated as a diagnostic tool in the non-invasive diagnosis of ectopic pregnancy. To assess the accuracy of a single serum progesterone measurement in the diagnosis of ectopic pregnancy, a meta-analysis was performed incorporating 26 studies evaluating the performance of single serum progesterone measurement in the diagnosis of ectopic pregnancy. A distinction was made in the diagnosis of pregnancy failure of any type versus viable intrauterine pregnancy and the diagnosis of ectopic pregnancy versus non-ectopic pregnancy. The reported sensitivity and specificity differed between the studies. Since there was a clear negative correlation between sensitivity and specificity, summary receiver-operating characteristic (ROC) curves could be estimated. The ROC curve for the diagnosis of pregnancy failure versus viable intrauterine pregnancy showed a good discriminative capacity. Single serum progesterone measurement could not discriminate between ectopic pregnancy and non-ectopic pregnancy. It is concluded that serum progesterone measurement can identify patients at risk for ectopic pregnancy, who need further evaluation, but its discriminative capacity is insufficient to diagnose ectopic pregnancy with certainty.     

Diagnostic reliability of vaginal ultrasound in ectopic pregnancy

The therapeutic approach to ectopic pregnancy (EP) has changed over the last decade. A prerequisite for a differentiated management is an early diagnosis of EP. This can be achieved by transvaginal sonography (TVS). The purpose of this study was to evaluate the accuracy of TVS in the diagnosis of EP. 184 patients with clinically suspected ectopic pregnancy were examined by TVS. In 103 cases suspicion of EP was confirmed, in 81 cases it was ruled out. All cases were evaluated by laparoscopy, D&C, serial HCG determinations or sonographic follow-up in case of an intrauterine pregnancy. Sensitivity of TVS in the diagnosis of EP was 96%, specificity 88%, the positive predictive value was 89%, the negative predictive value was 95%. Four cases with a false negative result at TVS were very early in pregnancy and were subjected to laparoscopy because of persistent high HCG values without demonstration of an intrauterine pregnancy. Five cases of sonographically confirmed ectopic pregnancies were missed by the first laparoscopy. These cases required intervention because of clinical symptoms and had low levels of HCG. TVS has a high diagnostic accuracy in the diagnosis of ectopic pregnancy.     

Early pregnancy diagnosis in alpaca (Lama pacos) and llama (Lama glama) by ultrasound

An ultrasonography study of early pregnancy diagnosis was carried out in 19 alpacas and 12 llamas, after controlled matings. The aim was to determine the earliest gestational age at which pregnancy diagnosis by transrectal ultrasonography could be achieved, and to generate an empirical formula for gestational sac diameter (GSD) growth as a function of gestational age (GA), allowing an estimate of GA during the first month of pregnancy. We found that pregnancy diagnosis may be carried out as early as 9 days after mating in alpacas and 7 days in llamas. This diagnosis was found to be accurate at 23 days in alpacas and 34 days in llamas. The empirical relations that best describe the relationship between GSD and GA were GA = logGSD + 1.2339/0.0585 r = 0.85; P < 0.001 in alpacas, and GA = logGSD + 1.2649/0.0546 r = 0.77, P < 0.001 in llamas, where GA is measured in days and GSD in centimeters. Our results also indicate that ultrasonography is a reliable technique for early pregnancy diagnosis. Furthermore, the empirical formulae reliably make it possible to estimate GA from GSD during the first month of pregnancy and their use might improve the efficiency of camelid breeders.     

Renal cell carcinoma

This is a report on two cases of mesomelic dysplasia Langer type. This is a rare kind of dwarfism which combines severe dwarfism with predominant shortening of the forearms and lower legs and other morphological abnormalities. The diagnosis can be made by ultrasonography in the early second trimester of the pregnancy.     

Liver disease in pregnancy

The liver is one of the many organs affected by the physiologic and hormonal changes that occur during pregnancy. Hepatic disorders diagnosed before pregnancy may be unaffected or exacerbated by the pregnant state. Liver disorders that are specific to pregnancy, including hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, preeclampsia/ eclampsia, HELLP, and hepatic rupture, may have a profound impact on the morbidity and mortality rates of mother and fetus. Although an unequivocal diagnosis is often difficult to make, it should be attempted in a timely manner so that optimal treatment can be determined. After the diagnosis is made, maximizing the health of the mother and fetus determines future management.     

Hospitalization for acute pyelonephritis in Manitoba, Canada, during the period from 1989 to 1992; impact of diabetes, pregnancy, and aboriginal origin

Population-based rates of hospitalization for acute pyelonephritis were estimated over 3 years with use of provincial administrative data on health care. Retrospective review of records of ICD9-CM discharge codes of pyelonephritis and urinary infection was performed in two acute care institutions to validate the discharge diagnosis; 80% of patients with a discharge diagnosis of pyelonephritis and 7% to 20% of patients with a discharge diagnosis of urinary infection met clinical criteria for admission for acute pyelonephritis. Mean rates of hospitalization +/- SD for acute pyelonephritis were 10.86 +/- 0.51 per 10,000 population among women and 3.32 +/- 0.27 per 10,000 population among men. From 18% to 31% of hospitalized women aged 20-39 years pregnant; 36% of 797 hospitalized women and 21% of 402 hospitalized men 40 years of age or older were diabetic. The hospitalization rates among Native American women with treaty status were five to 20 times greater than those among other women, which was partially attributable to a significantly greater frequency of pregnancy and diabetes in the former women. Hospitalization for acute pyelonephritis is common, and pregnancy and diabetes contribute substantially to hospitalization rates. The increased hospitalization rate among Native American women with treaty status is not fully explained by pregnancy or diabetes.     

Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996

OBJECTIVES: Published reports were reviewed to evaluate the characteristics of peripartal management and the late pregnancy outcome in women with pulmonary vascular disease (PVD). BACKGROUND: Pulmonary hypertension poses one of the highest risks for maternal mortality, but actual data on the maternal and neonatal prognosis in this group are lacking. METHODS: Reports published from 1978 through 1996 of Eisenmenger's syndrome (n = 73), primary pulmonary hypertension (PPH) (n = 27) and secondary vascular pulmonary hypertension (SVPH) (n = 25) complicating late pregnancy were included and analyzed using logistic regression analysis. RESULTS: Maternal mortality was 36% in Eisenmenger's syndrome, 30% in PPH and 56% (p < 0.08 vs. other two groups) in SVPH. Except for three prepartal deaths due to Eisenmenger's syndrome, all fatalities occurred within 35 days after delivery. Neonatal survival ranging from 87% to 89% was similar in the three groups. Previous pregnancies, timing of the diagnosis and hospital admission, operative delivery and diastolic pulmonary artery pressure were significant univariate (p < 0.05) maternal risk factors. Late diagnosis (p = 0.002, odds ratio 5.4) and late hospital admission (p = 0.01, odds ratio 1.1 per week of pregnancy) were independent predictive risk factors of maternal mortality. CONCLUSIONS: In the last two decades maternal mortality was comparable in patients with Eisenmenger's syndrome and PPH; however, it was relevantly higher in SVPH. Maternal prognosis depends on the early diagnosis of PVD, early hospital admission, individually tailored treatment during pregnancy and medical therapy and care focused on the postpartal period.     

The role of scientific societies

Ectopic pregnancy is one of the most common and dangerous complications of the early pregnancy period. Until now diagnosis has been late because major symptoms occur after tubal rupture and so only demolitive surgery has been possible. At present, with the appearance of ultrasound in obstetrics an earlier diagnosis of this pathology can be made before tubal rupture so medical treatment has become possible. We treated a series of twelve patients with early ectopic pregnancy (9 tubal and 3 with no localized site of implantation) with intramuscular 0.5 mg/kg methotrexate and oral 0.1 mg/kg of folic acid (Citrovorum Factor) on alternate days, in the attempt to reduce hospitalization and obtain more effective and safer medical management. We observed a fall in serum beta-HCG levels after one cycle of treatment in 11 out of 12 patients and after two cycles of therapy in the remaining case. Minimal side-effects were observed in four cases. Three pregnancies occurred after treatment before the advised interval time and ended in blighted ovum. Methotrexate systemic therapy can be considered an elective treatment and a sufficiently safe management in early unruptured ectopic pregnancy when a good clinical selection of patients is performed.     

Ectopic pregnancy associated with the intrauterine device: a study of seventy cases

Seventy cases of ectopic pregnancy associated with an IUD comprised 10% of all ectopics in a 9 year period. This increased to 15% in the last 19 months as more IUD's were in use. In two thirds of the ectopics the IUD had been in situ more than 1 year. Unusual bleeding and cramping attributed to the IUD obscured the diagnosis and resulted in removal or replacement of the IUD in over one half the cases 1 to 8 weeks before surgery. The episodic nature of the abdominal hemorrhage in two thirds of all ectopics resulted in surgery on day 44 average gestational age. The IUD is probably not causal in ectopic pregnancy but does not protect the predisposed patient from ectopic pregnancy which should be suspected in any patient with an IUD who has irregular bleeding and abdominal pain.     

Combined pregnancy]

Simultaneous intrauterine and ectopic pregnancy is a rare entity, with a difficult preoperative diagnosis, potentially dangerous for the mother and for the intrauterine pregnancy. A case of combined intra- and extrauterine pregnancy diagnosed at 5 weeks' menstrual dates in a 31-year-old woman non treated for infertility is described. Incidence, etiology, diagnosis and treatment of this uncommon complication are discussed.     

Urography during pregnancy

A review of 22,971 pregnancies from 1969-74 reveals that the reasons for requesting excretory urography were renal colic of pregnancy 11, pyelonephritis 8, renal contusion 2, threatened abortion 1, and suspected degeneration of fibroid 1. The final diagnoses were similar except that two patients with torsion of ovarian cysts and a renal calculus were discovered. The only intravenous pyelographic examination that was decisive for diagnosis was in a patient with a ureteric calculus. Careful clinical correlation should reduce excretory urography during pregnancy.     

Diagnosis of ectopic pregnancy--why we need a protocol

OBJECTIVE: To audit the management after instituting a screening programme for ectopic pregnancy in an institution with a protocol utilising ultrasound examination and serial human chorionic gonadotropin (hCG) and to examine the risk of missed diagnosis with deviation from the protocol. MATERIAL AND METHOD: A retrospective analysis of the management of 145 symptomatic patients in early pregnancies without intrauterine gestational sacs from ultrasound examinations, during the period April to June 1994 in Kandang Kerbau Hospital. Patients underwent serial hCG tests over 48 hours with or without repeat ultrasound scans before definitive treatment unless clinical indications for emergency surgery was necessary. RESULTS: There were 35 ectopic pregnancies (24%), 16 were viable intrauterine pregnancies (11%), 87 were non-viable pregnancies (60%) and 7 were of unknown outcome. There were much practice deviations from the protocol. Forty-four percent (64 cases) of the management decisions were made based on the initial clinical and ultrasound findings, and another 14% (21 cases) after a repeat assessment within the next day by either a repeat scan or serial serum hCG over one day. Among them, two of the 29 operated for suspected ectopic pregnancy were not ectopic (7%) and two of the 56 thought not to be ectopic, turned out to be ectopic (4%) (p < 10(-8)). Six percent (8 cases) defaulted after the initial assessments and one of them was found to be ectopic subsequently. Thirty percent (43 cases) adhered to the protocol. They had serial serum hCG done over two days. Seven of them requiring further repeats of serial serum hCG before management decisions were made. Four patients who were operated on were confirmed ectopic and 39 patients not operated on were not ectopic. Three percent (5 cases) were managed by serial hCG over 3 to 5 days and another 3% (4 cases) by repeating scan over one to two weeks without serial hCG. None of these was ectopic. The percentage change of hCG levels over two days gave indications of the likely diagnosis. CONCLUSION: Adhering to a protocol utilising the principle of ultrasound scan, serial hCGs and selective repeat ultrasound scans are highly recommended for the diagnosis of ectopic pregnancy. Any deviation from protocol is dangerous, with a 4% risk of missing an ectopic and a 7% risk of unnecessary operation for suspected ectopic pregnancy.     

Abnormal twin pregnancy--early resorption of a single fetus in a twin pregnancy pregnancy]

INTRODUCTION: Twin pregnancy presents a condition of development of two fetuses in the uterus and can be monozygotic (single ovum) and dizygotic (two ova). In case of fertilization and segmentation of one ovum monozygotic twins are produced, while in case of fertilization of two ova, which can originate from one or two Graff follicles, dizygotic twins are developed. The ratio of twin and single pregnancies is 1:89 (according to Hellin's law) (1). The incidence of twin and other multiple pregnancies is influenced by: race of parents, age and parity of mother, use of clomid and gonadotrophin to stimulate ovulation, discontinued use of contraceptive pills and certain seasons (exposure to sunlight) (1). Due to occurrence of numerous complications twin pregnancy and parturition are considered to be highly risky. This is supported by clinical data on more frequent spontaneous abortions--especially in monozygotic pregnancies, hypertension in pregnancy, hemorrhage of various etiologies, anemias, early rupture of amniotic membranes, hydramnios, premature deliveries, etc. Nowadays diagnosis of both twin and other multiple pregnancies in the early stage is required, in order to establish normal or pathological development of such pregnancies. As early as 6 gestation week in twin pregnancies it is possible to sonographically visualize two gestation sacs in the uterus, while in 7-8 gestation weeks it is possible to see two embryos with evidence of fetal heart rate. In early pregnancy a differentially-diagnosed uterus may be clinically enlarged due to: hydratidaform mole, uterine mioma or ovarian cyst. In later gestation confirmation of twin pregnancy is possible by clinical and sonographic examination and biochemical analyses (elevated values of HPL and -fetoprotein) and less frequently, by x-ray. Repeated sonographic examinations can reveal the following anomalies of twin pregnancies: one normal pregnancy with one sac containing no embryo, one sac containing no embryo and one sac with a dead fetus, fetuses without vitality in both gestation sacs, two ultrasound echoes from which only one normal fetus and one dead mummified fetus (fetus papiraceus) result within the uterus. One gestation sac may be resorbed during pregnancy, while the undamaged fetus continues to develop normally in the uterus. In certain cases the loss of one fetus is not accompanied by any clinical symptoms, and in others this can be accompanied by light hemorrhage. An initial twin pregnancy after the loss of one twin may end by a birth of one healthy infant. CASE REPORT: A patient aged 35 years, came for gynecological examination due to missed menstruation. Ananmesis showed that she had a nascent uterine myoma which was removed by myomectomy six months earlier, had one parturition four years earlier, and no abortions. The last menstrual period was on February 12, 1991. Clinical examination showed a somewhat larger uterus than would be normal for amenorrhea of 9-gestation week. By sonographic examination two regular gestation sacs were found in the uterus with fetal echoes present as well as heart rate in both fetuses (Figure 1). Embryo measurements were as follows: Fetus 1-CRL-22.5 mm, NEG-8 + 4, heart rate present. Fetus 2-CRL-23.6 mm, NEG-9, heart rate present (Figure 2). The patient was cautiously informed that two fetuses are visible in the uterus and that this is a sign of twin pregnancy, but for certain diagnosis a control examination was scheduled two weeks later. The sonographic examination after 14 days later showed discord in fetal growth (Figure 3). Embryo measurement in 11-gestation week rendered the following parameters: Fetus 1-CRL-22.8 mm, NEG 8 + 6, no heart rate registered (Figure 4), while the second fetus continued to develop and had the following characteristics: Fetus 2-CRL-50.5 mm, NEG 11 + 4, heart rate and fetal movement registered (Figure 5). During entire pregnancy the patient suffered no pain or any kind of hemorrhage. She took no drugs. (ABST     

A role for the nurse in caring for the individual suffering from rheumatoid arthritis

A review was made of the medical records of pregnant patients who had myomas that were documented by ultrasonographic studies. Only 42% of the myomas were diagnosed by physical examination. In most instances the clinical diagnosis was made when the neoplasm was large. However, when the myoma was 3 cm to 5 cm in diameter, the rate of detection on physical examination was only 12.5%. The relationship between the location of the myomas and the placental site emerged as a significant prognostic clue to the outcome of the pregnancy. Ten of 13 patients in whom there was contact between the two presented with complications of pregnancy, mainly antepartum bleeding and premature rupture of membranes. A prospective study is currently in progress.     

Combined intra-uterine and extra-uterine pregnancy associated with mild hyperstimulation syndrome after clomiphene ovulation induction

We report a combined intra-uterine and tubal pregnancy associated with mild ovarian hyperstimulation syndrome (OHSS) following ovulation induction by clomiphene. The diagnosis of ectopic pregnancy was originally missed until rupture occurred. OHSS confused the clinical picture, the important diagnostic feature being the fall in the haemoglobin concentration. The patient had a left partial salpingectomy and the uterine pregnancy progresses normally.     

First-trimester fetal chromosomal diagnosis using endocervical lavage: a negative evaluation

A report in the literature indicated that fetal cells could be obtained by endocervical lavage during the first trimester of pregnancy and successfully cultured. This would allow prenatal diagnosis earlier in pregnancy than is currently possible with second-trimester amniocentesis. Therefore, we attempted to confirm these findings. Our results indicated that the cultural cells were maternal in origin. We disagree with interpretations of the data given in the initial report and conclude that first-trimester prenatal diagnosis is not feasible at this time.     

Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum.

Examined the prevalence of depression in a heterogeneous sample of 360 pregnant women. Subjects were assessed with respect to both depressive symptomatology and diagnostic status during pregnancy and after delivery. At both assessments, approximately 25% of the sample reported elevated levels of depressive symptomatology. In contrast, 10% of the women met diagnostic criteria for depression during pregnancy, and 6.8% were depressed postpartum. However, only half of the cases of postpartum depression were new onset (3.4%); the remaining women receiving a diagnosis in the postpartum had also been depressed during pregnancy. Finally, depression during pregnancy was related to different sociodemographic variables than was postpartum depression, suggesting that depression at these two times may be associated with different psychological or etiological factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)