[Deforming endonasal mass during pregnancy]. / Deformierende endonasale Raumforderung während der Schwangerschaft.

This article presents the case of a 33-year-old woman who consulted the authors' ENT clinic in the 39th week of pregnancy with recurrent epistaxis. A livid endonasal mass was found on the left side, subtotally displacing the nose and leading to deformation of the external nose. External biopsy provided no indications of malignancy. Postpartum CT of the paranasal sinuses revealed a mass destroying the cartilaginous nasal septum. Endoscopic resection of the finding was performed with preservation of the clinically sound nasal septal cartilage. Histopathological examination revealed a capillary hemangioma, which was classified as granuloma gravidarum due to its occurrence during pregnancy.

Rituximab induction therapy for de novo ANCA associated vasculitis in pregnancy: a case report.

BACKGROUND: The diagnosis of antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is rare in pregnancy but potentially life threatening. There are no randomized controlled trials to guide the management of AAV in pregnancy and fetal safety data remains limited. Rituximab administration, a treatment for AAV, has been reported in pregnant women with reassuring fetal outcomes in the oncology and rheumatology literature; however, no published reports describe its use in AAV. CASE PRESENTATION: We present a case of de novo myeloperoxidase positive (MPO) AAV diagnosed at 22 weeks gestation. Clinical presentation included elevated serum creatinine at 177 µmol/L, hematuria and nephrotic range proteinuria along with high-titre MPO. Diagnosis was confirmed by renal biopsy. Patient was treated with methylprednisolone IV followed by oral prednisone 70 mg daily and Rituximab 650 mg IV weekly for four weeks followed by azathioprine maintenance therapy and prednisone taper. Delivery occurred at 29 weeks gestation via cesarean section for maternal neurologic symptoms concerning for preeclampsia. Maternal and fetal CD + 19 cells were depleted at time of delivery with associated fetal lymphopenia in the absence of infection or other complications related to Rituximab use. The patient experienced a reduction in proteinuria and inflammatory markers following Rituximab therapy; however, serum creatinine increased to 375 µmol/L by 11 weeks post-partum. CONCLUSION: We report the first use, to our knowledge, of Rituximab with corticosteroids for induction therapy of AAV in pregnancy.

Spontaneous rectus sheath hematoma in pregnancy and a systematic anatomical workup of rectus sheath hematoma: a case report.

BACKGROUND: Rectus sheath hematoma is a rare clinical diagnosis, particularly in pregnancy. Due to unspecific symptoms, misdiagnosis is likely and could potentially endanger a patient as well as her fetus. CASE PRESENTATION: A 26-year-old white woman presented with mild right-sided abdominal pain, which increased during palpation and movement, at 26 + 3 weeks' gestational age. Ultrasound imaging initially showed a round and well-demarcated structure, which appeared to be in contact with her uterine wall, leading to a suspected diagnosis of an infarcted leiomyoma. However, she reported increasing levels of pain and laboratory tests showed a significant drop in her initially normal hemoglobin level. A magnetic resonance imaging scan finally revealed a large type III rectus sheath hematoma on the right side. Because of progressive blood loss into her rectus sheath under conservative therapy, with a significant further decrease in her hemoglobin levels, surgical treatment via right-sided paramedian laparotomy was initiated. During the operation the arterial bleed could be ligated. She eventually achieved complete convalescence and delivered a healthy newborn spontaneously after 40 weeks of gestation. CONCLUSION: This case report highlights the clinical and diagnostic features of rectus sheath hematoma and shows the anatomical aspects of the rectus sheath, simplifying early and correct diagnosis.

[Lung ultrasonography for the diagnosis of pneumonia in pregnant women with blood system tumors].

AIM: To estimate the informative value of ultrasonography (USG) in the diagnosis of lung injuries in pregnant women with blood system tumors. SUBJECTS AND METHODS: Lung ultrasound was performed in 5 pregnant patients with blood cancers. The women's age was 29-38 years; gestational age was 14-33 weeks. Four women had different types of acute leukemia; one had primary mediastinal large B-cell lymphoma. All the women received chemotherapy for blood cancer. When there were signs of lung injury, USG was conducted, the results of which necessitated therapy or bronchoalveolar lavage (BAL). RESULTS: Three patients developed acute respiratory failure; 2 of them required noninvasive ventilation. Based on the detection of consolidation with a dynamic air bronchogram and pleural effusion, the authors diagnosed bilateral pneumonia and alveolar-interstitial syndrome in 1 patient, right-sided pneumonia in 1, left-sided one in 1, and transfusion-related pulmonary edema in 1. Lung ultrasound did not verify the diagnosis of pneumonia in 1 patient. According to USG data, BAL procedures were performed in 2 patients; one of them was diagnosed as having Pneumocystis pneumonia; the other was found to have no pathogens in lavage fluid. Treatment resulted in clinical improvements and normalization of the lung ultrasound pattern in all the pregnant women. Later on, 4 women delivered via cesarean section done at 32-34 weeks' gestation and gave birth to healthy babies. One patient died from infectious complications after chemotherapy. CONCLUSION: Lung sound may be used to diagnose lung injury in pregnant women with blood cancers.

Perfusion scintigraphy: diagnostic utility in pregnant women with suspected pulmonary embolic disease.

Pulmonary embolism (PE) is a major preventable cause of maternal mortality during pregnancy and accurate diagnosis is essential. Computed tomography pulmonary angiography (CTPA) is a robust diagnostic test in non-pregnant patients with suspected PE. The potential latent carcinogenic effects of CTPA-related breast irradiation mandates careful use of this technique in young women. The aim of this study was to determine the efficacy of perfusion scintigraphy as the first line investigation in pregnant women with suspected PE. All pregnant women referred for radiological investigation of suspected PE in a 5-year period from January 2001 to December 2005 were included. Demographic data and imaging studies were reviewed. Subsequent pregnancy outcome was determined by case note review. One hundred and five consecutive patients had either perfusion scintigraphy (Q scan) (n = 94), CTPA (n = 9) or both (n = 2), one patient presented twice. Q scans were the first line investigation in 96 (91%) patients. Eighty-nine (92%) scans were normal, seven (7%) were non-diagnostic and one (1%) was high probability. One patient had a thromboembolic event 3 weeks post partum. No adverse events were reported during the follow-up period. Pulmonary embolic disease is uncommon in pregnancy. Perfusion scintigraphy in pregnant patients has an excellent diagnostic yield. The percentage of non-diagnostic scans is much lower than in other patient groups. Scintigraphy imparts a significantly lower breast dose than CTPA and should be used as the first-line investigation in most pregnant patients with suspected PE.

Ultrasound diagnosis of severe thrombotic placental damage in the second trimester: an observational study.

OBJECTIVES: To screen women with uteroplacental insufficiency between 18 and 26 weeks' gestation for sonographic evidence of destructive placental lesions, to observe the effect of low molecular-weight heparin (LMWH) in these cases, and to compare the outcome with similar but untreated controls. METHODS: We screened 180 women at high risk for placental damage using 16-week maternal serum screening (alpha-fetoprotein and human chorionic gonadotropin), placental shape and texture, and uterine artery Doppler waveforms at the 18-20-week level II examination. Serial gray-scale examinations of placental texture were performed at 22, 24 and 26 weeks. LMWH was offered to women with ultrasound evidence of destructive placental lesions in the absence of intrauterine growth restriction and/or pre-eclampsia. RESULTS: We prospectively identified six women (3.3%) with abnormal maternal serum screening and uterine artery Doppler in whom abnormal placental texture (echogenic cystic lesions) suggestive of destructive lesions in the placental parenchyma was found either at the 18-20-week ultrasound examination (n = 4), or by 26 weeks of gestation (n = 2). All six received LMWH and had live births (gestational age at delivery, 33-37 weeks; birth weight, 1000-3200 g). A further 14 women were referred with similar multiparameter evidence of placental damage at or after 26 weeks, outside the screening study. All had significant fetal growth restriction and were therefore not offered heparin. In 9/14 cases there was a perinatal death. Ischemic and/or thrombotic placental pathology was confirmed in each case, but no maternal thrombophilia disorders were identified in the 20 women. CONCLUSIONS: Integrated biochemical and ultrasound testing of placental function at 16-20 weeks of gestation, followed by serial placental gray-scale ultrasound, may be an effective method of identifying a subset of pregnancies at high risk of adverse pregnancy outcome due to destructive lesions in the placental parenchyma. This strategy of identifying thrombo-occlusive placental lesions before the development of pregnancy complications may prove useful in the design of trials to study the effectiveness of LMWH in the prevention of clinical complications resulting from thrombo-occlusive placental disease.

[Spontaneous hematoma of the rectus sheath during pregnancy: a case report]. / Hématome spontané du muscle grand droit de l'abdomen au cours de la grossesse: à propos d'un cas.

A case of spontaneous rectus sheath hematoma is reported in a 32-year-old multigravida transferred to our antepartum unit for premature labor and persistent cough related to Candida dubliniensis upper airway infection. In pregnant patients presenting sudden-onset severe abdominal pain and parietal tenderness, there are two main differential diagnoses: abruptio placentae and aseptic necrobiosis of a uterine leiomyoma. The correct diagnosis may be obtained by ultrasonography and sometimes by computed tomography. In the present case an emergency cesarean section was performed at 35 weeks gestation after a 40% decrease in maternal hemoglobin and onset of fetal heart rate anomalies.

Hyperemic peripheral red marrow in a patient with sickle cell anemia demonstrated on Tc-99m labeled red blood cell venography.

A 25-year-old gravid woman, homozygous for sickle cell anemia, with a history of recent deep venous thrombosis, was examined using Tc-99m labeled red blood cell venography for recurrent thrombosis. Although negative for thrombus, the study presented an unusual incidental finding: the patient's peripheral bone marrow was hyperemic in a distribution consistent with peripheral red bone marrow expansion. Such a pattern has not been documented before using this technique. This report supports other literature that has demonstrated hyperemia of peripheral red bone marrow in other hemolytic anemias. This finding may ultimately define an additional role of scintigraphy in assessing the pathophysiologic status of the sickle cell patient.

Management of deep venous thrombosis in the pregnant female.

Deep venous thrombosis of the lower extremities is an uncommon but dreaded complication of pregnancy which can present diagnostic and therapeutic problems to the treating physician. From January 1, 1985, to December 31, 1988, 7867 deliveries were performed at St. Luke's Hospital. Five of these patients were pregnant women who were treated for deep venous thrombosis of the lower extremities. The women were either in their second or third trimester of pregnancy. The clinical diagnosis in each case was confirmed with duplex ultrasonography. Each patient was treated with 7 to 10 days of intravenous heparin therapy and then discharged on subcutaneous heparin therapy. There were no bleeding complications related to the heparin therapy. No patient developed a pulmonary embolism. Each patient delivered a normal child. The only complication was a heparin induced rash in one patient which resolved when a different preparation of heparin was used. The management of deep venous thrombosis in pregnancy is discussed.

Risks to the fetus of radiologic procedures used in the diagnosis of maternal venous thromboembolic disease.

The diagnosis of suspected venous thromboembolic disease during pregnancy is problematic because of the fear of fetal irradiation with routine diagnostic procedures. In order to develop rational guidelines, we have calculated levels of radiation exposure to the fetus for the common diagnostic procedures and conducted a literature review to examine the fetal risks associated with these levels of radiation. A small increase in the relative risk of childhood cancer is suggested by a literature review of outcomes following low dose (less than 5 rads), in utero radiation exposure. With careful use of the available procedures, a diagnosis of venous thrombosis is possible with fetal radiation exposure of less than 0.50 rads and a diagnosis of pulmonary embolism is possible with fetal radiation exposure of less than 0.05 rads. The risk of such exposure is small, both in relative and absolute terms.