Bilateral pheochromocytoma in pregnancy heralding multiple endocrine neoplasia syndrome IIA. A case report.

BACKGROUND: Multiple endocrine neoplasia syndrome type IIA (MEN IIA) has rarely been encountered in pregnancy. CASE: A 22-year-old, nulliparous woman developed bilateral pheochromocytomas during pregnancy. This finding aroused suspicion for MEN IIA, and close endocrinologic follow-up was arranged. Four years later, hyperparathyroidism developed, and the diagnosis was established. The patient underwent prophylactic total thyroidectomy with parathyroid exploration. CONCLUSION: This was the first case of MEN IIA in pregnancy in which the diagnosis was established prior to the development of medullary thyroid cancer, thereby allowing prophylactic thyroidectomy. The presence of bilateral neoplastic disease in young patients may be indicative of a hereditary predisposition to malignancy.

Operative management of ectopic pregnancy: a cost analysis.

OBJECTIVES: The purpose of this study was to analyze the cost for hospital-based services related to the operative management of ectopic pregnancies and determine the most cost-conscious approach by distinguishing the constituent components. STUDY DESIGN: This is a retrospective comparative review of every ectopic pregnancy that was surgically managed at the Memorial Medical Center of Long Beach. Unit cost estimates that are based on a cost accounting system were derived and compared between different procedures according to resources used among separate services. RESULTS: Hemodynamic instability significantly increases the cost of management by increasing the length of stay and laboratory costs. Among stable patients laparoscopic excision of ectopic pregnancies saves nearly 25% per case (p < 0.001) compared with laparotomy. However, when we compared all intended laparoscopic excisions (i.e., including the 21% of cases in which laparotomy was eventually done), the savings were markedly reduced. In addition, the cost savings was lost if patients undergoing laparotomy were discharged on or before postoperative day 2. Discharging patients after laparotomy on postoperative day 1 is the least costly management for operative treatment of ectopic pregnancy. CONCLUSIONS: Whereas laparoscopy may decrease recuperation time and incisional scarring, operative cost is not a significant reason to choose laparoscopy over laparotomy in a hemodynamically stable patient, especially as postoperative stays decrease.

Biometry of the fetal cisterna magna: estimates of the ability to detect trisomy 18.

Measurements of the fetal cisterna magna were obtained from a prospective sample of patients undergoing diagnostic obstetric ultrasound examinations. These normal measurements were then compared to a retrospective sample of ultrasound scans from fetuses with the diagnosis of trisomy 18 by amniocentesis. The fetal cisterna magna increases in size throughout pregnancy. The sample from fetuses with trisomy 18 was different and had a higher rate of small and large cisterna magnas. After the two samples were mixed, it was determined that a cut-off of 2.5 standard deviations for the fetal cisterna magna would give a sensitivity of 26.3%, specificity of 99.1%, positive predictive value of 50.0% and negative predictive value of 97.6% for trisomy 18. The probability that a fetal cisterna magna of abnormal size will predict trisomy 18 in an early second-trimester ultrasound examination with the 2.5 standard deviation cut-off was estimated at 0.019. A fetal cisterna magna that is of abnormal size appears to be of diagnostic value in identifying the fetus with trisomy 18, but its sensitivity is low.

Acute maternal renal insufficiency in premature labor treated with indomethacin.

Three cases of acute renal insufficiency in pregnant women who were treated with indomethacin for premature labor are reported. At the time of presentation, all three women had normal renal function but within 30 hours of indomethacin therapy they were noted to have significant decreases in urine output and rising serum creatinines. The average time to recovery of renal function was 5 days. A consistent feature in all three women was the development of dyspnea associated with hypoxemia.

Effect of uterine contractility and maternal hypotension on prolonged decelerations after bupivacaine epidural anesthesia.

Patients with prolonged decelerations after bupivacaine epidural anesthesia were matched with control patients. It was found that there were no differences in the decrease in mean arterial blood pressure after epidural anesthesia between those with prolonged decelerations (5 +/- 9 mm Hg) and those without (5 +/- 9 mm Hg). Uterine hypertonus was suggested as a cause in the prolonged deceleration group as a result of a higher rate of subjective impressions of uterine hypertonus (82% vs 11%) and more frequent use of terbutaline (30% vs 0%) after epidural anesthesia. With patients with internal uterine pressure monitors used as their own controls, it was also found that basal uterine tone was higher during periods when the deceleration occurred (26 +/- 9 mm Hg) than when it did not (13 +/- 4 mm Hg), and in comparison to windows before epidural anesthesia (12 +/- 5 mm Hg).

Fetal echocardiography: the prenatal diagnosis of a ventricular septal defect in a 14-week fetus with pulmonary artery hypoplasia.

As the result of auscultation of fetal bradycardia in a class C diabetic, real-time and M-mode echocardiography were performed at 14 weeks of gestation. M-mode evaluation revealed fetal bradycardia (70 beats per minute) with atrial and ventricular systole occurring simultaneously, suggesting a nodal rhythm. Real-time examination demonstrated a ventricular septal defect, pericardial effusion, ventricular wall hypertrophy, and a dilated aortic root. Also present were fetal ascites and situs inversus of the stomach. A repeat ultrasound examination revealed fetal death at 16 weeks of gestation. Autopsy confirmed the above structural abnormalities, and also demonstrated bilobed lungs, pulmonary artery and valve hypoplasia, midline small intestine, and asplenia.