First trimester ultrasonographic parameters in prediction of the course and outcome of monochorionic twin pregnancies.

BACKGROUND/AIM: The aim of the study was to evaluate the association and the potential predictive value of first trimester ultrasonographic parameters on the course and outcome of monochorionic diamniotic twin pregnancies. MATERIALS AND METHODS: A prospective cohort study was undertaken of 39 healthy women with consecutive monochorionic diamniotic twin pregnancies. During first-trimester screening, crown-rump length (CRL) and nuchal translucency (NT) were measured. The intertwin discordance in CRL and NT was determined. As pregnancy outcomes we assessed twins' live-born rates, Apgar scores, birth weight, pregnancy complications, and gestational week of delivery. RESULTS: None of the assessed pregnancy outcomes significantly correlated with standard CRL discordance ≥10%. The newly established cut-off was 3.75 mm for CRL and 1.3 mm for NT. Monochorionic diamniotic twins were delivered in a later gestational week and had better chance of survival if CRL intertwin difference was <3.75 mm. Apgar scores significantly negatively correlated only with NT of corresponding twins. When intertwin NT difference was ≥1.3 mm, twins had lower birth weight and pregnancy complications were more frequent. Regression models show that intertwin CRL difference <3.75 mm is a significant predictor of live-born monochorionic diamniotic twins. CONCLUSION: CRL and NT in monochorionic diamniotic twin pregnancies could indicate pregnancy complications and outcomes.

Small bowel incarceration as a complication of port site drainage following laparoscopic hysterectomy.

INTRODUCTION: Indication for surgical drainage may be prophylactic or therapeutic. However, surgical drains may cause complications. These complications can arise either following laparoscopic or open surgery. One of the rare complications resulting from drainage includes herniation of abdominal viscera at the drain site. The most common herniated abdominal organ is the small bowel. CASE REPORT: A 75-year-old woman underwent laparoscopic hysterectomy for atypical endometrial hyperplasia. After the operation, she developed small bowel herniation in the abdominal wall at the drain site, which was confirmed by multislice computed tomography. The patient underwent emergency relaparotomy that identified drain site incarceration of an ileal loop. Following resection of the incarcerated bowel, her postoperative recovery was uneventful. CONCLUSION: This case presents rare causative mechanism of intestinal obstruction. The possible occurrence of hernias following surgical drainage must be kept in mind.

Our experience with intraoperative cell salvage during cesarean delivery in women with uterine myomas--four case reports.

INTRODUCTION: Cesarean section is more frequent in pregnant women with uterine myomas, and is usually complicated with perioperative hemorrhage. In some cases, cesarean myomectomy represents an inevitable surgery, adding risk of hemorrhage occurrence. Massive obstetric hemorrhage is the most common cause of maternal mortality and morbidity. The aim of this study was to show our experience and results of the implementation of intraoperative blood salvage during cesarean section in the patients with uterine myomas. MATERIAL AND METHODS: The study encompassed four patients with uterine myomas who had cesarean delivery at our Department in the period from 2010 to 2011. RESULTS: Postoperative transfusion of packed red blood cells was given to one patient. No complications resulting form the intraoperative blood salvage were recorded in our research. CONCLUSION: Intraoperative blood salvage should be applied in patients with uterine myoma, and certainly in those who are planned for cesarean myomectomy and particularly in cases when massive intraoperative hemorrhage is expected.

Paravesical haematoma following placement of an isolated anterior mesh for cystocele repair.

INTRODUCTION: Pelvic organ prolapse is a substantial health problem for women around the world. Given the limitations of traditional surgery in the reconstruction of normal vaginal anatomy and function in genitourinary prolapse, various synthetic implants have been developed for surgical repair. Mesh procedures are gaining in popularity, encouraged by preliminary data. Although minimally invasive and relatively safe, serious complications following these procedures have been described. CASE REPORT: We presented a patient who had underwent an isolated anterior mesh procedure and developed postoperative haematoma which required surgical intervention. CONCLUSION: This report suggests that minimally invasive urogynecological procedures could result in significant complications. Thus, surgeons should be familiar with effective interventions in order to manage them.

Complications during cesarean delivery in a patient with two previous myomectomies.

INTRODUCTION: Myomas are associted with numerous pregnancy-related maternal and fetal complications, including high rate of cesarean deliveries. CASE OUTLINE: We present a woman with huge posterior myoma who had two previous myomectomies. During the cesarean section, the anatomy was found to be grossly distorted. Thus it was necessary to make an inverted T-incision on the uterus, which facilitated delivery of the fetus. The patients postoperative recovery was uneventful. CONCLUSION: This case illustrates the difficulties that may arise during cesarean section in the presence of uterine myomas in women with previous myomectomies. Clinicians should be prepared to manage those difficulties with inverted T-incision in order to prevent fetal injuries. Such operations should be performed by an experienced obstetrician.

Heterotopic pregnancy after in vitro fertilization and embryo transfer: a case report.

INTRODUCTION: Heterotopic pregnancy is a life-threatening complication of pregnancy defined as coexistent intrauterine and ectopic gestation. Its diagnosis is frequently overlooked and delayed. CASE OUTLINE: A 28-year-old woman experienced acute abdominal pain in pregnancy achieved by in vitro fertilization. Since all previous checkups indicated a normal course of pregnancy, the ectopic pregnancy was not suspected on admission. However, due to persistent hypotension, this diagnosis was also considered.Transvaginal ultrasound performed by an experienced obstetrician revealed an adnexal mass highly indicative of ectopic pregnancy. No fetal heart beats were visualized and the diagnosis of a missed abortion was made. A prompt laparotomy revealed a ruptured right ampullary pregnancy, and salpingectomy was performed. CONCLUSION: Although rare, heterotopic pregnancy should be considered in the differential diagnosis of abdominal pain in pregnancy. Every physician treating women of reproductive age should bear in mind the possibility of heterotopic pregnancy not only in patients with predisposing risk factors but also in those without them.

History of caesarean hysterectomy.

Caesarean hysterectomy evolved as a life-saving procedure following caesarean delivery. The concept underlying caesarean hysterectomy dates back to the mid 1700s and with a description of the procedure performed on laboratory animals. Eduardo Porro of Milan performed the first planned caesarean hysterectomy in which both the infant and the mother survived. He documented his operation in a paper published in 1876. Porro advocated hysterectomy combined with caesarean section to control post partum haemorrhage and to prevent infection. The maternal death rate following the operation remained high, but was substantly below the rate prior to the introduction of the procedure. The Porro procedure contributed to more favourable outcome for both the mother and the infant, having sterility and premature menopause as its side effects. Fortunately, the need for the procedure was soon minimised following the proposal to close the uterine incision with sutures. Although elective caesarean hysterectomy is still a controversial issue, there is no doubt that emergency post partum hysterectomy in case of massive obstetric haemorrhage is potentially life-saving. Over the past decades, the availability of potent uterotonics and broad-spectrum antibiotics, the development of embolisation techniques, and new methods of vessel ligation, have markedly reduced the need for caesarean hysterectomy, which, however, remains an important procedure in modern obstetric practice.

[Adnexal torsion during puerperium as a complication of delayed surgical treatment of ovarian tumor in pregnancy].

Ovarian tumors in pregnancy represent a significant issue both in terms of diagnostics and therapy. Increased use of the ultrasound in pregnancy in the last several decades has contributed to the rise in the number of diagnosed asymptomatic adnexal tumors with pregnant women. We present a case of a patient treated in our clinic for asymptomatic ovarian tumor, which was diagnosed in pregnancy. The patient underwent check-ups every four weeks, comprising clinical and sonographical examinations and relevant laboratory and tumor marker tests. The course of pregnancy was normal, with no detected tumor growth and with the tumor marker levels within the reference range. Following an uneventful delivery, she developed abdominal pains during the puerperium, and the adnexal torsion was diagnosed intraoperatively. The attitudes to treating of adnexal tumors in pregnancy are controversial, and there exist no defined treatment protocols. It is, therefore, necessary to make an individual evaluation of each case, and the relevant decisions should be made with the pregnant woman's informed consent. The adnexal torsion in the presented case can be explained by the size of the tumor as well as the progressive reduction of the size of the uterus due to the physical involution during puerperium.

Hysterectomy throughout history.

Hysterectomy, which is one of the most common surgeries performed on women, dates back to ancient times. The history of hysterectomy comprises biographies of many humble men and the significant individual efforts that they made to fight the skepticism of the medical communities of their times. Many of the pioneers were ignored. Although there are a number of alternatives to hysterectomy available, it remains one of the most frequently performed gynaecological operations. The introduction of antisepsis, anaesthesia, antibiotics and blood transfusion made hysterectomy a safe procedure. Nowadays, we distinguish three different surgical approaches to hysterectomy: vaginal, abdominal and laparoscopic. The limitations of conventional laparoscopy have led to the development of robotic surgery, which has evolved over the past decade from simple adjustable arms to support cameras in laparoscopic surgery to more sophisticated four-armed machines now being in use worldwide.