Umbilical endometriosis.

We report two women who presented with a recurrent, mildly painful, bluish nodule in the umbilicus. Both patients complained of local tenderness and occasional bleeding that increased during menstruation. Neither patient had had previous pelvic surgery. Excision of the lesions revealed a primary umbilical endometriosis; in one case, a simultaneous laparoscopy showed a pelvic endometriosis. We review the current literature and discuss the possible etiopathogenesis and when a laparoscopy is indicated to diagnose a concomitant pelvic endometriosis. Umbilical endometriosis is a very rare disease but should be considered in the differential diagnosis of umbilical lesions.

[Shorter delivery time after induction with misoprostol]. / Kürzere Geburtsdauer nach Einleitung mit Misoprostol.

INTRODUCTION: Increasing evidence has demonstrated that intravaginal misoprostol (PGE1) is more effective in labor induction than dinoprostone (PGE2). Several studies have demonstrated that the administration of PGE1 instead of PGE2 reduces the induction-to-delivery interval. However, it has not been fully investigated on which phase of birth the activity of PGE1 is stronger than that of PGE2. We undertook this study to investigate whether the activity of the two prostaglandins are different over time during the induction-to-delivery interval. MATERIAL AND METHODS: 155 patients undergoing induction of labor with 50 micrograms intravaginal PGE1 were compared with 174 patients treated with 3 mg PGE2. In both groups the procedure was repeated 6, and 24 hours after the first dose until labor was achieved. Induction-to-initiation of labor time, duration of labor stages, induction-to-delivery time, mode of delivery, maternal and neonatal morbidity and changes in Bishop score were compared. RESULTS: Demographic characteristics, indications for induction, mode of delivery, fetal weight, maternal and neonatal morbidity and duration of the labor stages were similar between the groups. A significant difference was found in terms of: induction-to-initiation of labor interval (7.37 h [1-68] vs. 11.25 h [1-74], p < 0.01) and induction-to-delivery interval (11.5 h [2.5-89] vs. 14.4 h [2.7-94], p < 0.05). The Bishop score at the time of the second administration was significantly different from that at admission in the PGE1 group compared to the PGE2 group [PGE1: 4.8 +/- 2/5.6 +/- 1.9, p < 0.0005; PGE2: 3.9 +/- 2/4.2 +/- 1.4, p = 0.09]. This effect of PGE1 remained significant after correction for various explanatory variables. CONCLUSIONS: The stronger effect of PGE1 is the consequence of a faster cervical ripening, which in turn leads to a quicker achievement of active labor. DISCUSSION: Intravaginal PGE1 compared to PGE2 reduces significantly the induction-to-delivery time.

[Severe autoimmune thrombocytopenia in pregnancy]. / Schwere Autoimmunthrombozytopenie in der Schwangerschaft.

Maternal thrombocytopenia is a frequent finding in pregnancy. The clinically important causes of maternal thrombocytopenia in pregnancy are gestational thrombocytopenia and autoimmune thrombocytopenia. We report a case of refractory idiopathic thrombocytopenic purpura by a 30-year-old pregnant woman, gravida 3, para 2, successfully treated with high dose corticosteroids and immune globulins.

Prenatal assessment of Wharton's jelly in umbilical cords with single artery.

OBJECTIVE: To investigate whether the amount of Wharton's jelly in non-malformed fetuses with a single umbilical artery is different from that of fetuses with a normal umbilical cord. METHODS: We evaluated patients with singleton pregnancies, non-malformed fetuses and single umbilical artery undergoing sonographic evaluation at a gestational age ranging from 19 to 41 weeks' gestation. The cross-sectional areas of the umbilical cord and of the umbilical vessels were measured. The amount of Wharton's jelly was calculated by subtracting from the total cross-sectional area of the umbilical cord the areas of the artery and of the vein. The umbilical cord cross-sectional area, the umbilical artery and vein areas as well as the amount of Wharton's jelly were plotted on previously published nomograms. RESULTS: Twenty-two patients met the inclusion criteria. The umbilical cord cross-sectional area was within the normal range in 20 (90.1%) cases. The umbilical artery and vein areas were above 2 standard deviations from the mean in 20 cases and in 11 cases (50%), respectively. The amount of Wharton's jelly was below 2 standard deviations from the mean in all cases. An abnormal insertion of the umbilical cord (marginal, velamentous) was present in five cases (22.7%). CONCLUSIONS: A reduction of Wharton's jelly is frequently present in cases of single umbilical artery. The increased perinatal morbidity and mortality observed in cases of single umbilical artery, even in the absence of congenital or chromosomal abnormalities, could be in part the consequence of a reduced amount of Wharton's jelly.

[Medically indicated termination of pregnancy in giant uterine myoma and mono-amniotic twin pregnancy: a case report]. / Medizinisch indizierter Schwangerschaftsabbruch bei riesigem Uterus myomatosus und monoamnioter Zwillingsschwangerschaft: eine Fallvorstellung.

We report the rare combination of a monoamniotic twin pregnancy with giant uterine leiomyomas in a 33-year-old para 0, gravida 1. Considering the restricted capacity of uterine expansion during pregnancy and the known complications associated with myomas, as well as the elevated morbidity and mortality of monoamniotic twin pregnancies, we opted for a medically indicated abortion at 12 weeks' gestation. After abortion the patient developed fever and abdominal pain. In differential diagnosis we considered endomyometritis and necrosis of the myomas. Despite adequate conservative treatment the symptoms persisted and myomectomy was performed in view of the patient's desire to maintain fertility.

Screening for personality disorders in a nonclinical population.

Based on the Inventory of Interpersonal Problems (IIP), the IIP-PD and the IIP-C screening scales were developed to distinguish personality disorder (PD) from non-PD and Cluster C from other PD, respectively, in a clinic population. Two studies were conducted to determine (a) validity and reliability of these IIP scales for PD screening in a nonclinical population, (b) specificity of IIP-C for identifying Cluster C, and (c) usefulness of the IIP scales for screening Cluster A. College students were screened using the IIP scales (Study 1, N = 454, Study 2, N = 87). High and low scorers completed PD-related questionnaires in Study 1 and a clinical interview for PD symptomatology in Study 2. Results indicated strong test-retest reliability, internal consistency, and factorial, convergent, and external validity. The scales tapped a common deficit in interpersonal relatedness, with some distinction between externalizing and internalizing dimensions, respectively, and both scales were positively and significantly associated with schizotypal traits. In conclusion, the IIP-PD and IIP-C are useful and valid screening instruments for identifying any versus no PD in nonclinical populations.

Duration of pregnancy after carbon dioxide laser conization of the cervix: influence of cone height.

OBJECTIVE: To determine if carbon dioxide laser conization of the cervix is a risk factor for preterm delivery in subsequent gestations and to evaluate whether there is any relationship between cone height and duration of pregnancy. METHODS: Patients of fertile age who had carbon dioxide laser conization were followed for reproductive events. Cases were matched one-to-one with controls for known risk factors for preterm delivery. Pregnancy duration, rate of preterm birth, and mode of delivery were studied. Parametric and nonparametric tests were used for statistical analysis. Logistic regression analysis and Cox proportional hazard modeling were used to investigate the relationship between cone height and subsequent preterm delivery. RESULTS: Sixty-four women with singleton pregnancies after carbon dioxide laser conization and 64 controls were included in the study. Overall, no difference was found in the rate of preterm delivery and duration of pregnancy. However, women with cone height of at least 10 mm had a higher rate of preterm delivery than either those with cone height less than 10 mm (five of 23 versus one of 41, P = .01) or the controls (five of 23 versus three of 64, P < .05). Cone height of at least 10 mm remained significant in predicting the occurrence of preterm delivery and the duration of pregnancy after adjusting for known risk factors (odds ratio 11.1, P < .05). CONCLUSION: Cone height of at least 10 mm is an independent risk factor for the duration of pregnancy and for the occurrence of preterm delivery in the subsequent gestation.

Higher rate of fetal acidemia after regional anesthesia for elective cesarean delivery.

OBJECTIVE: To determine the prevalence of fetal acidemia associated with regional anesthesia for elective cesarean delivery in healthy paturients with uncomplicated singleton term pregnancies. METHODS: This was an epidemiologic study using the data base of the Swiss obstetric study group (Arbeitsgemeinschaft Schweizerischer Frauenkliniken). After the exclusion of cases with extraneous factors that may have affected the health of the neonate, we analyzed the umbilical artery pH, Apgar score, and other neonatal outcome measures after cesarean delivery with reference to the anesthetic technique. RESULTS: From 1985 to 1994, 327,763 deliveries, including 40,858 (12.47%) by cesarean, were registered in the data base. Of these, 5806 patients fulfilled the study criteria. The study population included 1002 spinal, 2155 epidural, and 2649 cases of general anesthesia. The frequency of fetal acidemia (pH less than 7.10) was significantly increased in the spinal-anesthesia group (odds ratio [OR] 4.67; 95% confidence interval [CI] 2.73, 8.01) and in the epidural group (OR 2.39; 95% CI 1.42, 4.04) compared with the general-anesthesia group. CONCLUSION: The rate of fetal acidemia is significantly increased after regional anesthesia. This risk must be judged in light of the risks inherent with general anesthesia.

[Intravenous leiomyomatosis]. / Intravenöse Leiomyomatose.

A 49-year-old woman presented with a uterine tumour with solid and cystic parts. Extension of the tumour into the broad ligament was noted at the operation with wormlike plugs of tumour within the veins. The histological diagnosis of intravenous leiomyomatosis was evident. The disease turned out to be far advanced: a long continuous intraluminal mass extending from the iliac veins to the right ventricle made a second operation with thoracotomy and laparotomy mandatory. Postoperative follow-up showed so far, 1.5 years after operation, no evidence of recurrence. Intravenous leiomyomatosis is a very uncommon finding. Though it is histologically a benign smooth-muscle tumour, the biological behaviour with intravenous growth which may involve the right side of the heart, is quite aggressive. About 100 cases were reported in the literature; in no case could the diagnosis be made before surgery.

[Prenatal diagnosis of umbilical cord hemangioma in increased alpha fetoprotein]. / Pränatale Diagnose eines Nabelschnur-Hämangioms bei erhöhtem Alphafötoprotein.

In a patient with elevated serum alpha-fetoprotein a little haemangioma of the umbilical cord is diagnosed by ultrasound in the 21st week of pregnancy. So far only nine reports exist of prenatal diagnosed haemangiomas of the cord. Severe complications like rupture, cord haematoma, non-immune hydrops fetalis and polyhydramnions as well as a perinatal mortality of 35% have been reported. Therefore, intensive surveillance during pregnancy is mandatory.

[Severe accidental magnesium poisoning in a twins pregnancy in the 32nd week of pregnancy]. / Schwere akzidentelle Magnesiumintoxikation bei einer Zwillingsschwangerschaft in der 32.SSW.

Faculty administration of a magnesium infusion in the 32nd week of a twin-pregnancy caused a life-threatening situation. Oxygen mask ventilation, calcium i.v. and forced diuresis rapidly improved the condition of the patient and thus prevented any sequelae for mother and children.

[Ovarian cancer in ovarian remnant syndrome]. / Ovarialkarzinom bei Ovarian Remnant Syndrome.

We present the second published case of an ovarian cancer in Ovarian Remnant Syndrome. Only explorative laparotomy confirms the diagnosis. Conservative treatment is often without success and may conceal the diagnosis of a malignant process.

[Pregnancy in diabetes insipidus--a case report with review of the literature]. / Schwangerschaft bei Diabetes Insipidus--ein Fallbericht mit Literaturübersicht.

A 32 year old I P II G with preexisting diabetes insipidus was treated with 1-(3-mercaptopropionic acid)-8-d-arginine vasopressin (DDAVP) during pregnancy. An otherwise normal pregnancy was marked only with an excessive weight increase. A healthy girl was delivered by secondary cesarean section at term. Postoperative the mother developed a water intoxication accompanying oxytocin-infusion. During nursing the diabetes insipidus improved significantly whereby DDAVP doses could be reduced to 20-10 percent. We suppose an overreaction to endogene oxytocin with an antidiuretic effect.

[Spontaneous vaginal rupture with prolapse of the small intestine]. / Spontane Scheidenruptur mit Dünndarmprolaps.

Spontaneous rupture of the vaginal vault is a rare event. Patients at risk are postmenopausal. Very often they show symptoms of an enterocele or have been operated before vaginally. Treatment is always by surgery. Whether it can be done vaginally or by laparotomy, depends on the local situation. To prevent recurrence, a double closure of the lesion is necessary, often combined with colpocleisis, colpectomy, sacropexie or obliteration of the "cul-de-sac".

[Sinusoidal CTG in feto-maternal transfusion--case report]. / Sinusoidales CTG bei feto-maternaler Transfusion--Kasuistik.

In a casuistic report we describe sinusoidal heart rate pattern in severe feto-maternal-transfusion. Hypoxia, acidosis and fetal anaemia have to be excluded, when sinusoidal heart rate pattern is registrated.