[Delayed birth of the second child in multiple gestation]. / Uitgestelde geboorte van de tweede van een meerling.

Five case histories illustrate the issue of delayed interval deliveries. In the first two cases, the first child was born at a gestational age of 20 and 18 weeks, respectively. The first woman (40 years old) gave birth to the second child after successful prolongation of pregnancy to a gestational age of 38 weeks. In the second case (28 years old), the attempt to delay delivery failed and the second child was born at 19 weeks of gestation. The third case (32 years old), illustrates the enormous differences in neonatal course between a child born at 26 weeks of gestation, who had to be treated at length for respiratory distress syndrome, hypotension and patent ductus arteriosus, and his twin brother born two weeks later and who recovered more quickly. The fourth case (24 years old) describes delayed delivery to allow administration of antenatal glucocorticoids. The last case (32 years old) deals with a serious maternal complication of placental abruption during an attempt to delay the birth of the second twin. Early tocolytic and antibiotic therapy may delay delivery and, in combination with antenatal glucocorticoids to stimulate lung maturation, may thereby improve the condition of the second twin. The role of cervical cerclage remains controversial. There is an important publication bias in the literature due to under-reporting of the failed attempts of delayed deliveries. In multiple gestation with imminent very preterm birth, delayed delivery of the second child is a feasible management option.

[Pain in the symphyseal region after parturition: possibly osteomyelitis]. / Pijnklachten in de symfyseregio na een bevalling: mogelijk osteomyelitis.

A 29-year-old woman 3 weeks after her first childbirth suffered from atypical and progressive pain in the pelvis, which turned out to be a symptom of osteomyelitis of the pubic bone. She recovered after treatment with antibiotics and 6 weeks' stabilization of the pelvis. Symptoms of osteomyelitis resemble those of pubic osteitis, symphyseal rupture and symphysiolysis. Radiologically, osteomyelitis is characterized by development of infiltrates, cortical involvement and local osteopenia. Isolation of micro-organisms in a bone culture after puncture is regarded as proof of the diagnosis. The treatment is primarily with antibiotics, if abscesses or sequestra develop these should be relieved and/or removed.

Metastasis of breast carcinoma to a primary mucinous cystadenocarcinoma of the ovary.

A case of a patient with breast cancer metastatic within the tumor stroma of a primary ovarian carcinoma is presented. This finding is to the best of our knowledge the first case reported. The encountered diagnostic problems are discussed. A distinct peroperative frozen section diagnosis on the large, cystic, partially necrotic ovarian mass was not possible because of sampling problems. A comparable immunohistochemical staining pattern of cells being CEA negative, OC-125 negative, and HMFG-1 positive was found in both the primary breast tumor and in the solid epithelial parts in the tumor stroma of the left-sided ovarian carcinoma, as well as in the stroma of the right ovary. Immunohistochemical findings in the left-sided epithelial cystic ovarian tumor showed, as expected, apical reactivity with antibodies directed against CEA, whereas OC-125 and HMFG-1 were negative. Ploidy analysis showed that the primary breast carcinoma and the stromal part of left ovarian malignancy had the same aneuploid stemlines (DNA index = 1.18). The epithelial lining of the cystic ovarium carcinoma not showing the presence of metastatic lesion in the stroma showed the presence of a diploid GO,1 population only. These results show that DNA flow cytometry and immunohistochemistry may be helpful in assessing the origin of the malignancies in this unusual double presentation of both metastatic breast cancer and primary ovarian carcinoma.

Conservative management of placental abruption complicated by severe clotting disorders.

Placental abruption resulting in fetal death may seriously affect maternal health, especially when clotting disorders arise. The prevailing view is that the clotting system will only normalize after the uterus has been evacuated and therefore prompt delivery, often by induction of labor, is advocated. Over a 3-year period, 16 cases (0.35%) of intra-uterine fetal death due to placental abruption occurred at Leiden University Hospital. Five cases were complicated by severe clotting disorders. All women delivered vaginally. No maternal deaths occurred. In contrast to most authors, we present data showing that in four out of five cases the clotting system started to normalize before the uterus was emptied. We suggest that an expectant approach until recovery of the coagulopathy is safer than aiming at a quick delivery. After stabilization of the clotting disorder, one may then consider evacuation of the uterus, if need be by induction of labor.

The accuracy of frozen section diagnosis of ovarian tumors.

We compared all frozen section examinations of ovarian tumors during a 6-year period in our institute with the final diagnosis from paraffin sections. In this period, 946 ovarian tumor specimens were removed for histologic assessment; 176 (18.6%) had frozen section examination. Final histological diagnosis was divided into benign (55.1%), borderline malignant (10.3%), and malignant (34.6%). Sensitivity of the frozen section method for malignant or borderline disease was 83.5% and specificity for a benign lesion, 92.8%. Predictive values and 95% confidence intervals were computed: 100% (93-100%) for malignancy, 62% (32-86%) for borderline malignancy, and 92% (85-96%) for a benign disease. Diagnostic problems occurred in large borderline tumors of mucinous cell type. Analysis of the 12 false negative diagnoses revealed that a sampling error was involved in 11 cases. A judgment error was made in the only false positive and in 1 out of 12 false negative frozen section diagnoses. It is concluded that when surgeons and pathologists are aware of the limitations of frozen section diagnosis of ovarian tumors, peroperative histologic examination can be worthwhile and prevent under- and overtreatment of gynecologic patients.

[A patient with pulmonary edema following use of beta-sympathomimetics (tocolytic agents)]. / Een patiënte met longoedeem na gebruik van beta-sympathicomimetica (tocolytica).

During her pregnancy (29 weeks) a 29-year-old woman complained of pain in the right upper quadrant of her abdomen. Gallbladder stones were demonstrated by ultrasonography. Because of recurrent pain attacks cholecystectomy was performed. Continuous intravenous tocolytic therapy, fenoterol bromide (Parusisten), was given during and following surgery. Two days after this first laparotomy she underwent a second laparotomy because of unexplained abdominal pain and blood loss. A subhepatic haematoma was found without a specific origin for the blood loss. Shortly after this second operation she developed clinical signs and abnormalities on the chest X-ray compatible with severe pulmonary oedema. She needed artificial ventilation for 15 days. There appears to be a pathophysiological relationship between the development of pulmonary oedema and tocolytic therapy. Probably, pulmonary oedema may develop during tocolytic therapy as a result of several factors such as increased hydrostatic pressure, decreased oncotic pressure and perhaps capillary leakage.