Heterotopic triplet pregnancy after in vitro fertilization with favorable outcome of the intrauterine twin pregnancy subsequent to surgical treatment of the tubal pregnancy.

Heterotopic triplet pregnancy is an exceptionally rare medical condition. The broad use of assisted reproductive technologies has contributed to the increase of ectopic and subsequently heterotopic pregnancy rate, masking a life-threatening condition for the gravid and the intrauterine pregnancy. We describe a case of a woman with heterotopic triplets at 9(+4) gestational week following transfer of three embryos obtained by in vitro fertilization techniques. The ectopic tubal pregnancy was ruptured and salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed to the delivery by cesarean section of two healthy twins at 36(+2) gestational age. Heterotopic triplets with tubal ectopic are a special diagnostic and therapeutic challenge for the obstetrician. High index of suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy.

Markers of stem cells in human ovarian granulosa cells: is there a clinical significance in ART?

BACKGROUND: The purpose of the study was to determine the incidence of gene expression of Oct-4 and DAZL, which are typical markers for stem cells, in human granulosa cells during ovarian stimulation in women with normal FSH levels undergoing IVF or ICSI and to discover any clinical significance of such expression in ART. METHODS: Twenty one women underwent ovulation induction for IVF or ICSI and ET with standard GnRH analogue-recombinant FSH protocol. Infertility causes were male and tubal factor. Cumulus-mature oocyte complexes were denuded separately and granulosa cells were analyzed for each patient separately using quantitative reverse-transcription-polymerase chain reaction analysis for Oct-4 and DAZL gene expression with G6PD gene as internal standard. RESULTS: G6PD and Oct-4 mRNA was detected in the granulosa cells in 47.6% (10/21). The median of Oct-4 mRNA/G6PD mRNA was 1.75 with intra-quarteral range from 0.10 to 98.21. The OCT-4 mRNA expression was statistically significantly correlated with the number of oocytes retrieved; when the Oct-4 mRNA expression was higher, then more than six oocytes were retrieved (p=0.037, Wilcoxon rank-sum). No detection of DAZL mRNA was found in granulosa cells. There was no additional statistically significant correlation between the levels of Oct-4 expression and FSH basal levels or estradiol peak levels or dosage of FSH for ovulation induction. No association was found between the presence or absence of Oct-4 mRNA expression in granulosa cells and ovarian response to gonadotropin stimulation. Also, no influence on pregnancy was observed between the presence or absence of Oct-4 mRNA expression in granulosa cells or to its expression levels accordingly. CONCLUSIONS: Expression of OCT-4 mRNA, which is a typical stem cell marker and absence of expression of DAZL mRNA, which is a typical germ cell marker, suggest that a subpopulation of luteinized granulosa cells in healthy ovarian follicles (47.6%) consists of stem cells, which are not originated from primordial germ cells. Absence of Oct-4 gene expression in more than half of the cases means probably the end of the productive journey of these cells, towards the oocyte.

Expression of antiapoptosis gene survivin in luteinized ovarian granulosa cells of women undergoing IVF or ICSI and embryo transfer: clinical correlations.

BACKGROUND: The purpose of the study was to determine the incidence of survivin gene expression in human granulosa cells during ovarian stimulation in Greek women with normal FSH levels, undergoing IVF or ICSI and to discover any correlation between levels of gene expression and clinical parameters, efficacy of ovulation or outcomes of assisted reproduction. METHODS: Twenty nine women underwent ovulation induction for IVF or ICSI and ET with standard GnRH analogue-recombinant FSH protocol. Infertility causes were male and tubal factor. Cumulus-mature oocyte complexes were denuded and the granulosa cells were analyzed for each patient separately using quantitative reverse transcription polymerase chain reaction analysis for survivin gene expression with internal standard the ABL gene. RESULTS: The ABL and survivin mRNA were detected in granulosa cells in 93.1%. The expression levels of survivin were significantly lower in normal women (male infertility factor) compared to women with tubal infertility factor (p = 0.007). There was no additional statistically significant correlation between levels of survivin expression and estradiol levels or dosage of FSH for ovulation induction or number of dominant follicles aspirated or number of retrieved oocytes or embryo grade or clinical pregnancy rates respectively. CONCLUSIONS: High levels of survivin mRNA expression in luteinized granulosa cells in cases with tubal infertility seem to protect ovaries from follicular apoptosis. A subpopulation of patients with low levels of survivin mRNA in granulosa cells might benefit with ICSI treatment to bypass possible natural barriers of sperm-oocyte interactions.

Malignant gastrointestinal stromal tumor presenting with hemoperitoneum in puerperium: report of a case with review of the literature.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that develop in the wall of the gastrointestinal tract and their diagnosis during pregnancy or puerperium is extremely rare. CASE: A 28-year old patient presented with acute abdomen due to hemoperitoneum from a large mass arising of the small intestine with distended vessels on its top and a ruptured superficial vessel bleeding into the peritoneal cavity. The patient was at the tenth postpartum day of her first pregnancy. The preoperative diagnosis was a possible ovarian or uterine mass. After an emergency exploratory laparotomy a segmental bowel resection was performed, removing the tumor with a part of 3-cm of the small intestine. Histology revealed GIST with maximum diameter of 13 cm and mitotic rates more than 5 mitoses per 50 high power fields with some atypical forms, indicating a high risk malignancy. Immunohistochemical staining of the tumor tissue demonstrated strongly positive reactivity to CD 117 (c-kit) and CD34 in almost all the tumor cells. The patient was treated with oral imatinib mesylate (Gleevec) 400 mg daily for one year. Three years after surgery, the patient was alive without evidence of metastases or local recurrence. CONCLUSION: Considering that only few patients with gastrointestinal stromal tumors have been reported in the obstetrical and gynecological literature, the awareness of such an entity by the obstetricians-gynecologists is necessary in order to facilitate coordinated approach with the general surgeons and oncologists for the optimal care of the patients.

Prenatal diagnosis of fetal hemivertebra at 20 weeks' gestation with literature review.

Hemivertebra is a rare congenital spinal malformation, where only one side of the vertebral body develops, resulting in deformation of the spine, such as scoliosis, lordosis, or kyphosis. We present the ultrasonographic features of a fetus with hemivertebra at 20 weeks' gestation confirmed by post mortem radiography and pathological examination. The prenatal literature on this disorder is also reviewed. Useful background information is provided for both clinicians and other health professionals who are not familiar with this condition.

Double vagina and cervix communicating bilaterally with a single uterine cavity: report of a case with an unusual congenital uterine malformation.

BACKGROUND: The existence of a longitudinal vaginal septum with double cervix communicating bilaterally with a nonseptate uterine body and normal adnexa is an unusual müllerian anomaly. CASE: A 43-year-old woman presented with menorrhagia and duplication of the cervix and vagina. Afibromatous uterus was suggested by clinical examination and confirmed by ultrasonography. The patient underwent total abdominal hysterectomy with bilateral salpingooophorectomy. The surgical specimen revealed a fibromatous uterus with double cervix communicating bilaterally with a nonseptate uterine body; both adnexa were normal. CONCLUSION: This rare müllerian anomaly is inconsistent with the classical embryologic theory of caudal to cranial müllerian development but supports the alternative embryologic hypothesis suggested by Müller et al, according to which fusion and absorption begin at the isthmus and proceed simultaneously in both the cranial and caudal directions.

Asynchronous bilateral adnexal torsion in a 13-year-old adolescent: our experience of a rare case with review of the literature.

Adnexal torsion is a serious condition and delay in surgical intervention may result in loss of the tube and/or ovary. Children and adolescents who have suffered from uterine adnexal torsion may be at risk for asynchronous torsion of the contralateral uterine adnexa. We report the case of sequential bilateral torsion of uterine adnexa in a 13-year-old girl, resulting in right and subsequently left salpingo-oophorectomy because of gross evidence of total necrosis in both uterine adnexa. After the castration the patient was started on hormone replacement therapy. Families of children who suffered from ovarian torsion and unilateral ovarian loss should be educated about the risk of the contralateral ovary for future torsion and should be encouraged to seek immediate medical help with the recurrence of abdominal pain.

Heterotopic pregnancy in a natural conception cycle presenting with tubal rupture: a case report and review of the literature.

BACKGROUND: Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. CASE: We report such a case in a 28-year old para 0, gravida 1 woman with no known risk factors. The ectopic pregnancy was diagnosed after rupturing at 11 weeks, 4 weeks after diagnosis of the intrauterine pregnancy, and resected via laparotomy. A healthy baby was delivered without complications at 40 weeks gestation. CONCLUSION: Heterotopic pregnancy is possible with natural conception and the survival of the intrauterine fetus is feasible.