Uterine mullerian adenosarcoma with sarcomatous overgrowth fatal recurrence within two weeks of diagnosis: a case report.

Mullerian adenosarcoma with sarcomatous overgrowth (MASO) is a rare variant of uterine sarcomas, associated with postoperative recurrence, metastases and a fatal outcome. The mean age at diagnosis is 54.5 years. A 37-year-old nullipara presented with irregular vaginal bleeding, a normal pelvic examination, and an initially negative ultrasound. Repeat ultrasound one month later revealed an 11-cm heterogeneous pelvic mass. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Pathology confirmed uterine MASO. Computed tomography 2 weeks postoperatively showed a huge mass compatible with recurrence. Patient died 2 weeks later. MASO is rarely diagnosed in women in their 4th decade. This case stresses that these aggressive tumors should be considered in the differential of patients with vaginal bleeding and pelvic masses irrespective of their age.

A tale of 2 pedunculated myomas.

We present 2 unusual cases of prolapsed pedunculated submucous myomas. In 1 patient, the prolapsed part measured 12 cm, with a 64-cm intrauterine part. The second patient had prolapsed pedunculated submucous myoma, which subsequently retracted into the uterus. Gynecologists should be aware of unusual presentations of pedunculated submucous myoma to plan surgery.

Placenta previa-accreta: risk factors and complications.

OBJECTIVE: The purpose of this study was to identify risk factors and complications of placenta previa-accreta (PA). STUDY DESIGN: Patients with placenta previa (n = 347) delivered over 20 years were reviewed, divided into PA (cases, n = 22) and no accreta (controls, n = 325), and compared. RESULTS: Cases were older with a higher incidence of smoking and previous cesarean delivery (CS). Grandmultiparity, recurrent abortions, anterior/central placentae, and low socioeconomic status were similar. PA incidence increased with the number of previous CS: 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. Hypertensive disorders (odds ratio [OR] 13.9, 95%CI 2.1-91.2], P = .006), smoking (OR 3.4, 95%CI 1.1-10.2, P = .031) and previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009) were selected by the stepwise logistic regression analysis as predictors of PA. Cases had a longer hospital stay, a higher estimated blood loss, and need for transfusion. Cesarean hysterectomy and hypogastric artery ligation were only performed in PA cases. The 2 groups had a similar delivery gestational age and neonatal outcome. CONCLUSION: Hypertensive disorders, smoking, and previous cesarean are risk factors for accreta in placenta previa patients. Placenta previa-accreta is associated with higher maternal morbidity, but similar neonatal outcome compared with patients with an isolated placenta previa.

Splenomegaly, pancytopenia and pregnancy: a case report and review of the literature.

We present a 35-year-old previously healthy primigravida who presented at 26(4/7) weeks of gestation with pancytopenia and hepatosplenomegaly. She received 10 transfusions and delivered at 34(4/7) weeks of gestation by cesarean section. Two months later following splenectomy, she was diagnosed with malaria. Physicians should have a high index of suspicion for malaria in the context of splenomegaly and pancytopenia in pregnancy even in the absence of fever.

Breech presenting twin A: is vaginal delivery safe?

The aim of our study was to compare the neonatal outcome of vaginally delivered breech-presenting twins (VD) to those delivered by cesarean (CS). Maternal and neonatal charts of all live, non-anomalous twins delivered at > or =25 weeks of gestation, in a single tertiary care center, over an 11-year period were reviewed. Of 517 twins delivered, 130 breech-presenting twins were analyzed. Thirty-five (26.9%) were delivered vaginally and 95 (73.1%) by cesarean. More patients presented in labor with advanced cervical dilation in the VD compared to the CS group. There was no difference in the incidence of respiratory distress syndrome, intraventricular hemorrhage, need for mechanical ventilation, length of nursery stay or neonatal mortality rate when twin A was compared in the two groups. However, one breech-presenting twin in the VD group had a traumatic delivery at 32 weeks of gestation that caused a spine fracture followed by immediate neonatal death. Although there seems to be no compromise in the immediate neonatal outcome of breech-presenting twins delivered vaginally compared to those delivered by cesarean, the case of head entrapment that led to intrapartum death is quite alarming. Based on our study, we cannot advocate normal vaginal delivery when twin A is non-vertex: cesarean seems to be a safer route of delivery.

Pregnancy outcome in women with prosthetic heart valves.

OBJECTIVE: This study was undertaken to evaluate the risks and pregnancy outcome in women with prosthetic heart valves on different anticoagulent regimens. STUDY DESIGN: A retrospective chart review of 82 pregnancies in 33 women with mechanical valve prostheses at a tertiary referral center from 1987 to 2002. The main outcome measures were major maternal complications and perinatal outcome. RESULTS: The valve replaced was mitral (60.6%), aortic (18.2%), and both (21.2%). Fifty-four pregnancies (65.9%) resulted in live births, 9 (11.0%) had stillbirths (all on warfarin), and 12 (14.6%) had spontaneous and 7 (8.5%) therapeutic abortions (all on warfarin). The rate of spontaneous abortion was highest in women on warfarin throughout pregnancy (P < .01). The live birth rate was higher in women on heparin compared with those on warfarin (P < .01), and in those on heparin/warfarin compared with warfarin alone (P < .01). There were no maternal deaths; however, 3 patients had mitral valve thrombosis (2 on heparin and 1 on warfarin) necessitating surgery in 1 patient and medical thrombolysis in 2 patients. Hemorrhagic complications occurred in 5 patients, 4 of whom required transfusion. CONCLUSION: No single anticoagulant regimen confers complete protection from thromboembolic phenomena in pregnancy. Despite a high maternal morbidity rate, the perinatal outcome is acceptable when pregnancy progresses beyond the first trimester.