Emergency Obstetric Hysterectomy after Conservative Management of Placenta Accreta.

Background: Obstetric hemorrhage is a frequent and life-threatening complication of either vaginal or cesarean delivery. It can be due to many causes, one of which is placenta accreta, the abnormal invasion of the placenta into the myometrial wall of uterus. Ultrasonography is the first line diagnostic method that can lead to the diagnosis of placenta accreta although, the depth of penetration is estimated by magnetic resonance imaging. Placenta accreta is a life-threatening situation requiring an experienced health care team for its management. Hysterectomy is usually performed although, conservative management might be preferred in carefully selected cases. Case Presentation. A 32-year-old woman (G2, P0) who had an inconsistently monitored pregnancy appeared at a regional hospital with contractions at 39th week of gestation. In her first pregnancy, she was subjected to cesarean section due to delay in second stage of labor and unfortunately her child died due to sudden cardiac death. During C-section, placenta accreta was identified. Given her previous history and her desire to maintain fertility, conservative management was initially planned to preserve her uterus. However, due to persisting vaginal bleeding immediately after delivery an emergency hysterectomy was performed. Conclusion: Conservative management of placenta accreta can be considered in some special cases with the aim to spare fertility. However, if bleeding cannot be controlled during the immediate postpartum period, emergency hysterectomy is unavoidable. A specialized multidisciplinary medical team is required to optimize management.

Acute intestinal obstruction in pregnancy after previous gastric bypass: A case report.

Background: Intestinal obstruction is an extremely rare condition among pregnant women, but it can be life-threatening for both mother and fetus. Case presentation: A woman in her late twenties with no history of previous pregnancies was admitted to hospital due to regular preterm contractions and cervical shortening. Seven days after her admission, while the contractions had stopped and cervical length was stable, she complained of acute abdominal pain. Bowel obstruction was suspected due to the patient's history of gastric bypass 5 years earlier for weight loss. Computed tomography was not performed due to risk of fetal irradiation. Conservative management was attempted, but the patient stopped passing flatus and started vomiting. The fetus was delivered by emergency exploratory laparotomy, during which small bowel obstruction due to adhesions was identified and resolved. Conclusion: Although uncommon during pregnancy, small bowel obstruction is far more common in women who have had previous abdominal operations, especially involving the stomach. Obstetricians must maintain a high level of suspicion since this condition can be life-threatening for both the mother and the fetus.

Multidose methotrexate treatment of cornual pregnancy after in vitro fertilization: Two case reports.

BACKGROUND: An ectopic pregnancy, when the gestational sac is implanted outside of the uterine cavity, can be life-threatening. A cornual pregnancy is the most dangerous type of ectopic pregnancy since it can be misdiagnosed easily and has high mortality rate. It is diagnosed when the implantation site is at the junction between the fallopian tube and the uterus. For a successful outcome, early diagnosis and management are critical. The traditional management is surgical, involving cornual resection or hysterectomy, which, however, affects fertility. Thus, conservative management involving administration of methotrexate should always be considered. CASE PRESENTATION: The article describes to two women in their early forties with no previous children (G1, P0) and diagnosed with a cornual pregnancy at 7 and 8 weeks of gestation following in vitro fertilization. Given their hemodynamic stability and their desire to conserve fertility they were treated conservatively. The two patients had similar ultrasound findings and blood results. The main difference was the presence of an embryonic heart beat in one case. Successful management was accomplished with multidose methotrexate and leucovorin during hospitalization for 8 days and close monitoring for the next 30 days as outpatients. In addition, the second woman was given a transvaginal injection of potassium chloride (KCL) to stop embryonic cardiac activity. CONCLUSION: Conservative management of cornual pregnancies applying multidose therapy of methotrexate and leucovorin is a safe treatment when patients are asymptomatic and preserves fertility.

Morbidity after local excision of the transformation zone for cervical intra-epithelial neoplasia and early cervical cancer.

The awareness that cervical intra-epithelial neoplasia (CIN) treatment increases the risk of preterm birth has led to major changes in clinical practice. Women with CIN have a higher baseline risk of prematurity but local treatment further increases this risk. The risk further increases with increasing cone length and multiplies for repeat excisions; it is unclear whether small cones confer any additional risk to CIN alone. There is no evidence to suggest that fertility is affected by local treatment, although this increases the risk of mid-trimester loss. Caution should prevail when deciding to treat women with CIN of reproductive age. If treatment is offered, this should be conducted effectively to optimise the clearance of disease and minimise the risk of recurrence. Colposcopists should alert women undergoing treatment that this may increase the risk of preterm birth and that they may be offered interventions when pregnant. The cone length should be clearly documented and used as a risk stratifier.

Successful conservative medical management of an interstitial ectopic pregnancy at 10 weeks of gestation: A case report.

BACKGROUND: Interstitial pregnancy is a rare type of ectopic pregnancy, accounting for 2-6% of ectopic pregnancies, but it can be life threatening. There is no clear consensus on management, either surgical or medical, and it depends on hemodynamic stability and whether fertility-sparing treatment is requested. CASE PRESENTATION: We present the case of a 35-year-old woman (G2, P1) who was diagnosed with an interstitial pregnancy at 10 weeks of gestation following in vitro fertilization. She was hemodynamically stable and requested fertility-sparing treatment. She was managed successfully with methotrexate and folinic acid with a hospital stay of 17 days. CONCLUSION: Interstitial pregnancy can be managed medically. However, these patients require close monitoring.

T cell receptor (TcR) beta chain transgenic mice: studies on allelic exclusion and on the TcR+ gamma/delta population.

To study allelic exclusion of TcR genes we analyzed two types (I and II) of TcR beta transgenic mice. T cells derived from both types of mice contained similar amounts of transgenic RNA transcripts; however, surface expression of the transgenic beta chain was drastically reduced in type II compared to type I. In type I transgenic mice, productive rearrangements and expression of endogenous TcR beta genes were suppressed whereas on T cells of type II mice, both transgenic and endogenous TcR beta chains were expressed on the surface of the same cell. These findings suggest that allelic exclusion of TcR genes in beta transgenic mice depends on amount and/or onset of transgene expression during thymic development. Furthermore, TcR gamma rearrangements and the population of TcR gamma/delta-bearing double-negative CD4-CD8- thymocytes were reduced fivefold in type I transgenic animals. However, the V gamma usage and the gamma/delta+ dendritic epidermal cell populations appeared normal. RNase protection analysis further revealed low levels of transgenic TcR beta chain transcripts in TcR+ gamma/delta CD4-CD8- thymocytes. These results suggest that the beta transgene only quantitatively influences the gamma/delta T cell compartment, and supports the independence of the gamma/delta population.