Arteriovenous malformation of the uterus after a midtrimester loss: a case report.

BACKGROUND: Arteriovenous malformations (AVMs) of the uterus are rare but potentially life-threatening lesions. The typical presentation includes intermittent, heavy and profuse vaginal bleeding, often refractory to medical therapy. CASE: We present the case of a 25-year-old woman presenting 18 months after a 22-week pregnancy loss complicated by a postpartum curettage for retained placenta. The patient's initial symptoms included irregular and extremely heavy vaginal bleeding. Several transfusions of packed red blood cells were required because of severe anemia. On transfer to our institution, evaluation with ultrasound and hysteroscopy revealed a large AVM in the fundus of the uterus, apparently fed by both the right and left uterine arteries. After 2 embolization procedures of the uterine arteries, the patient experienced a recurrence of her symptoms, requiring definitive treatment with a hysterectomy. CONCLUSION: AVMs of the uterus are a rare cause of vaginal bleeding. AVMs should be considered in the differential diagnosis for the patient with bleeding refractory to medical management and a history of prior uterine surgery. Although unsuccessful in our case, uterine artery embolization remains a viable treatment option, particularly in patients wishing to retain their reproductive capacity.

Fetal death.

The death of a formed fetus is one of the most emotionally devastating events for parents and clinicians. With improved care for conditions such as RhD alloimmunization, diabetes, and preeclampsia, the rate of fetal death in the United States decreased substantially in the mid twentieth century. However, the past several decades have seen much greater reductions in neonatal death rates than in fetal death rates. As such, fetal death remains a significant and understudied problem that now accounts for almost 50% of all perinatal deaths. The availability of prostaglandins has greatly facilitated delivery options for patients with fetal death. Risk factors for fetal death include African American race, advanced maternal age, obesity, smoking, prior fetal death, maternal diseases, and fetal growth impairment. There are numerous causes of fetal death, including genetic conditions, infections, placental abnormalities, and fetal-maternal hemorrhage. Many cases of fetal death do not undergo adequate evaluation for possible causes. Perinatal autopsy and placental examination are perhaps the most valuable tests for the evaluation of fetal death. Antenatal surveillance and emotional support are the mainstays of subsequent pregnancy management. Outcomes may be improved in women with diabetes, hypertension, red cell alloimmunization, and antiphospholipid syndrome. However, there is considerable room for further reduction in the fetal death rate.

[Management of maternal tetanus contracted by an obstetric procedure].

A 34-year-old woman from the Philippines showed difficulty in opening the mouth. She had no wounds in the last one mouth, but was treated with an obstetric procedure after stillbirth 16 days before in the Philippines. She showed trismus, rigidity and muscle pain, but no muscle spasms, dyspnea and autonomic dysfunction. In this case, it is supposed that the obstetric procedure is the origin of the injury. In Japan, this is the first report of maternal tetanus.

Management strategies for abnormal early pregnancy: a cost-effectiveness analysis.

OBJECTIVE: To assess the potential effectiveness and costs of 4 commonly used strategies to manage abnormal early pregnancies (AEPs). STUDY DESIGN: A decision analysis model was constructed to compare 4 strategies to manage AEPs: (1) observation, (2) medical management, (3) manual vacuum aspiration (MVA), and (4) dilation and curettage (D&C). RESULTS: MVA was the most cost-effective strategy, at dollar 793 per cure, for a total cost of dollar 377 million per 500,000 women and a cure rate of 95%. D&C was more effective than MVA, with a cure rate of 99%, but was more expensive (dollar 2,333 per cure, for a total cost of dollar 1.2 billion). D&C cured 20,000 more patients than MVA; however, at a substantial cost of dollar 38,925 per additional cure. With other estimates at baseline, MVA remained more cost-effective than D&C until the efficacy of MVA was < 82% or the cost of D&C was < dollar 240. CONCLUSION: MVA is the most cost-effective strategy for managing AEP and would be appropriate in settings in which resources are limited. D&C remains a reasonable strategy; however, one must spend dollar 38,925 per additional cure. In the United States, MVA would save dollar 779 million per year relative to D&C.

Conduta obstétrica no óbito fetal / Obstetrical management of fetal death

Apesar de 80 a 90 por cento dos fetos mortos poderem ser eliminados espontaneamente após duas a três semanas do óbito, a induçäo do parto tem sido a conduta mais utilizada. O objetivo deste estudo foi avaliar os resultados da induçäo de parto em casos de óbito fetal intra-útero com idade gestacional a partir de 20 semanas. Foi um estudo clínico descritivo realizado no Hospital Maternidade Leonor Mendes de Barros, em Säo Paulo. Foram analisados 122 gestantes com esse diagnóstico quanto às características sociodemográficas, causas de óbito fetal. antecedentes obstétricos e características do parto (forma de induçäo, via de parto, complicaçöes). Os procedimentos estatísticos utilizados foram cálculo da média e desvio-padrao e X2. As principais causas identificadas de morte fetal foram hipertensäo arterial e infecçöes. A droga mais utilizada para a induçäo do parto foi o misoprostol (37,7 por cento), seguido da ocitocina (19,7 por cento). Em 27 por cento dos casos o trabalho de parto iniciou espontaneamente. O tempo médio de induçäo foi de 3 horas. A maior parte teve parto vaginal e em 9,1 por cento a cesárea foi realizada. Concluiu-se que a induçäo de parto de feto morto é segura e eficaz, independentemente do método utilizado. O misoprostol, utilizado por via vaginal, é especialmente útil nos casos de colo desfavorável, por seu efeito modificador sobre ele.

Conduta conservadora na gestaçäo gemelar com óbito de um dos conceptos / Conservative management in multifetal pregnancies with death of one of the fetuses

Os autores descrevem cinco casos de gestaçao gemelar com morte de um dos fetos diagnosticados no segundo ou terceiro trimestre, na Maternidade-Escola Assis Chateaubriand, no período de outubro de 1991 a setembro de 1995. Foi adotada conduta conservadora em todas elas com monitorizaçao rigorosa do perfil da coagulaçao materna e do bem-estar fetal. Nao houve nenhum caso de coagulopatia materna, defeitos estruturais fetais ou morte do segundo gemelar. Tivemos duas placentas dicoriônicas e três monocoriônicas. Só evidenciamos morbidade perinatal em um recém-nascido, prematuro, com retardo do crescimento intra-uterino e icterícia neonatal. Nossos dados, embora com casuística pequena, suportam a adoçao de conduta conservadora, principalmente nas gestaçoes dicoriônicas.

Uso del misoprostol por vía vaginal para la inducción del trabajo de parto en pacientes con muerte fetal intrauterina / Vaginal use of misoprostol for induction of delivery in patients with fetal intrauterine death

En el Hospital Materno Infantil Germán Urquidi de Cochabamba Bolivia, 53 pacientes con diagnóstico de Síndrome de Muerte Fetal, que reunierón condiciones obstétricas, fueron sometidas a inducción de parto con Misoprostol de un universo de 120 que representa el 44 por ciento osis individualizadas, en fondo de saco vaginal, entre junio de 1992 a Enero de 1995. La respuesta exitosa en 83 por ciento de los casos usando solo Misoprostol se incremento cuando se asocio a ocitocina alcanzando 96 por ciento de exito. No se observo una sola paciente que haya sido insensible a la acción contractil y de maduración cervical de esta prostaglandina. En caso de ruptura uterina se observó cuando de asocio a ocitocina, que termino en histerectomía. Debido a los óptimos resultados los autores concluyen que el misoprostol es una opción eficaz en la resolución del óbito fetal y profilaxis de sus complicaciones.

Higroma quístico cervical / Cervical cystic hygroma

Se presenta un caso clínico de diagnóstico antenatal ultrasonográfico de higroma quístico con muerte fetal intrauterina y su seguimiento desde el punto de vista clínico y anatomopatológico

Experiencia con prostaglandinas E2 en gel intracervicales y tabletas intravaginales en óbitos fetales / Experience with E2 prostaglandins in intracervical gel and intravaginal pills in death fetus

Se presenta nuestra experiencia clínica con el uso de prostaglandinas E2 en gel intracervicales y en tabletas intravaginales en la inducción del parto o abortos en fetos muertos. Considerados globalmente las 50 pacientes, el éxito fue de 70 por ciento, excluídos los 9 casos de fetos acráneos; esta proporción de éxito asciende a 77,7 por ciento en los casos de aborto retenido y a 78,26 por ciento en los casos de feto muerto in utero

Qué hacer con los padres bajo el impacto de la muerte perinatal: mesa redonda

Durante el X Curso de Actualización Pediátrica del Departamento de Pediatría de la Fundación SantaFé de Bogotá, el Dr. Sergio Casanova, Director de la Unidad Psiquiátrica del Hospital Infantil Lorencita Villegas de Santos y Profesor de Psiquiatría de la Facultad de Medicina de la Escuela Colombiana de Medicina, presentó en una mesa redonda su experiencia de varios años en la atención de padres cuyos hijos han muerto.

Prostaglandin F2 alpha for interrupting pregnancy, managing intrauterine death and molar pregnancy and inducing labor.

Serial intramuscular injections of 250 microgram of 15 (S), 15-methyl-prostaglandin F2 alpha were given to 105 women every 1-3 hours in an attempt to induce second-trimester abortion (N = 80) or labor (N = 25), the latter because of late intrauterine death or anencephaly. The treatment was highly successful; the cumulative expulsion rates at 12 and 24 hours were 69% and 95%, respectively. There were no serious complications, and significant alterations in the mother's vital signs were uncommon. Gastrointestinal side effects are tolerable if the woman is properly premedicated and maintained on the antiemetic, antidiarrheic and analgesic treatments.

PIP: Serial intramuscular injections of 250 mcg of 15(S,15-methyl-prostaglandin F2alpha were given to 105 women every 1-3 hours in an attempt to induce second trimester abortion (N=80) or labor (N=25). Patients were divided into 5 groups: those with missed abortions; those with pregnancy terminations; those with molar pregnancy; those with intrauterine death; and those where labor was induced with a live anencephalic fetus. The treatment was highly successful; the cumulative expulsion rates at 12 and 24 hours were 69% and 95% respectively. There were no serious complications, and significant alterations in the mother's vital signs were uncommon. Gastrointestinal side effects are tolerable if the woman is properly premedicated and maintained on the antiemetic, antidiarrheic, and analgesic treatments.

Management of missed abortion, intrauterine death and hydatidiform mole using prostaglandin E2.

PIP: Intravenous infusions of prostaglandin E2 (PGE2) in various concentrations were given to 36 patients with missed abortion, 4 with a hydatidiform mole and 25 with fetal death in utero occurring after the 28th week of pregnancy. In all instances the drug was diluted by adding it to 0.9% sodium chloride solution. Initially, it was used in a concentration of 6 micrograms per milliliter, but as the trial progressed this was reduced to 5 micrograms per milliliter and finally to 1.5 micrograms per milliliter. No patient needed more than 6 micrograms per minute. On no occasion was the infusion kept running for more than 15 hours. The 6 micrograms per milliliter dose was administered to 3 patients, 1 with an intrauterine death and 2 with missed abortions. The mean induction-delivery interval was 13 hours 5 minutes and the mean total dose in 3 successful infusiosn was 4.00 milligrams. The 5 micrograms per milliliter dose was given to 26 patients, 17 with missed abortions, 8 with intrauterine death, and 1 with a hydatidiform mole. The mean induction delivery interval in the 23 successful infusions was 9 hours 43 minutes with a mean total dose of prostaglandin PGE2 of 2.20 milligrams. This was much less than the mean total dose administered to the 3 failed inductions. The 1.5 microgram per milliliter dose was given to 17 patients with missed abortion, 16 with intrauterine death and 3 with hydatidiform mole. In 1 case of missed abortion the 1st infusion failed to initiate uterine evacuation. The mean induction-delivery interval was 10 hours 22 minutes with a mean total dose of 1.9 milligrams of prostaglandin. None of the 65 patients had any excess blood loss at delivery. Gastrointestinal symptoms occurred during 13 of the 33 infusions involving the higher concentration of prostaglandin.^ieng