The multifactorial aetiology and management of premenstrual dysphoric disorder with leuprorelin acetate.

Up to 18% of women of reproductive age may experience symptoms during the luteal phase of the menstrual cycle known as premenstrual syndrome (PMS) or its more severe form, premenstrual dysphoric disorder (PMDD). A plethora of symptoms have been described, but both are commonly associated with other mood-related disorders such as major depression causing significant life impairment. Originally known as late luteal phase dysphoric disorder in the DSM-III-R (American Psychiatric Association 1987), the syndrome was renamed PMDD in the DSM-IV (American Psychiatric Association 1994). Between 3% and 8% of women meet the diagnostic criteria for PMDD. Currently, there is no consensus on its aetiology although it is thought to be multifactorial. Biological, genetic, psychological, environmental and social factors have all been suggested. However, an altered sensitivity to the normal hormonal fluctuations that influence functioning of the central nervous system is thought most likely. PMDD is identified in the DSM-5 by the presence of at least five symptoms accompanied by significant psychosocial or functional impairment. During evaluation, it is recommended that clinicians confirm symptoms by prospective patient mood charting for at least two menstrual cycles. Management options include psychotropic agents, ovulation suppression and dietary modification. Selective serotonin reuptake inhibitors (SSRIs) are considered primary therapy for psychological symptoms. Ovulation suppression is another option with the combined oral contraceptive pill (COCP) or GnRH (gonadotropin-releasing hormone) agonists. Rarely symptoms warrant a bilateral oophorectomy and a 6-month trial of GnRH agonists prior to surgery may be prudent to determine its potential efficacy. The authors present the case of a multiparous woman in her mid-30s experiencing severe symptoms during the luteal phase of her menstrual cycle. A trial of the contraceptive pill and SSRIs were unsuccessful. Treatment with leuprorelin acetate (Prostap) improved her symptoms. She therefore elected to undergo a bilateral oophorectomy with resolution of her symptoms. She started hormone replacement therapy (HRT). This case demonstrates the multifactorial aetiology of PMDD and the challenges in its management. Women with PMDD suffer functional impairments comparable with other depressive disorders and yet PMDD and its impact remain under-recognised. As the psychological nature and consequences of PMDD often seem indistinguishable from symptoms of other mental health difficulties, this condition presents distinct diagnostic challenges for healthcare professionals. It is crucial to establish the correct diagnosis using clearly defined criteria because if it is left untreated, it can cause considerable impairment to the woman's quality of life.

Abdominal ectopic pregnancy.

An ectopic pregnancy (EP) accounts for 1-2% of all pregnancies, of which 90% implant in the fallopian tube. An abdominal ectopic pregnancy (AEP) is defined as an ectopic pregnancy occurring when the gestational sac is implanted in the peritoneal cavity outside the uterine cavity or the fallopian tube. Implantation sites may include the omentum, peritoneum of the pelvic and abdominal cavity, the uterine surface and abdominal organs such as the spleen, intestine, liver and blood vessels. Primary abdominal pregnancy results from fertilisation of the ovum in the abdominal cavity and secondary occurs from an aborted or ruptured tubal pregnancy. It represents a very rare form of an EP, occurring in <1% of cases. At early gestations, it can be challenging to render the diagnosis, and it can be misdiagnosed as a tubal ectopic pregnancy. An AEP diagnosed >20 weeks' gestation, caused by the implantation of an abnormal placenta, is an important cause of maternal-fetal mortality due to the high risk of a major obstetric haemorrhage and coagulopathy following partial or total placental separation. Management options include surgical therapy (laparoscopy±laparotomy), medical therapy with intramuscular or intralesional methotrexate and/or intracardiac potassium chloride or a combination of medical and surgical management. The authors present the case of a multiparous woman in her early 30s presenting with heavy vaginal bleeding and abdominal pain at 8 weeks' gestation. Her beta-human chorionic gonadotropin (bHCG) was 5760 IU/L (range: 0-5), consistent with a viable pregnancy. Her transvaginal ultrasound scan suggested an ectopic pregnancy. Laparoscopy confirmed an AEP involving the pelvic lateral sidewall. Her postoperative 48-hour bHCG was 374 IU/L. Due to the rarity of this presentation, a high index of clinical suspicion correlated with the woman's symptoms; bHCG and ultrasound scan is required to establish the diagnosis to prevent morbidity and mortality.

Severe pre-eclampsia as a rare cause of profound hyponatraemia.

Profound hyponatraemia, defined as sodium <125 mmol/L, is a very rare complication of pre-eclampsia (PET) with a relative paucity of cases reported. Pre-eclampsia is a multisystem disorder with a maternal mortality of up to 20%. Hyponatraemia is associated with disease severity, twin pregnancy, advanced maternal age, in vitro fertilisation and HELLP (haemolysis, elevated liver enzymes and low platelets). The authors present the case of a low-risk nulliparous woman presenting with frontal headache and normal BP at 31+2 weeks gestation. Laboratory investigations confirmed a sodium of 123 mmol/L. Her urine protein creatinine ratio was 322 mg/mmol. She developed PET (BP 171/100 mm Hg) refractory to pharmacological management. She underwent an emergency lower segment caesarean section and was delivered of a live neonate. The maternal serum sodium normalised within 24 hours. Hyponatraemia should be regarded as a marker of severity in the setting of pre-eclampsia and may be an indication for an expedited delivery. Prompt management is required to prevent convulsions, maternal mortality and adverse fetal outcomes.

Interstitial ectopic pregnancy successfully treated with methotrexate.

An ectopic pregnancy (EP) occurs when the fertilised ovum implants outside the endometrial cavity. An EP has an incidence of 1%, with the majority occurring in the fallopian tube. It has a maternal mortality of 0.2 per 1000, with about two-thirds of these deaths associated with substandard care. An interstitial pregnancy occurs when the EP implants in the interstitial part of the fallopian tube. An interstitial ectopic pregnancy (IEP) shows few early clinical symptoms, hence it is associated with serious or fatal bleeding and a mortality rate up to 2.5%. With the advent of transvaginal ultrasound scan (TV USS), correlated with serum beta human chorionic gonadotropin (BHCG) assay, earlier diagnosis of an EP can be established. An EP is often diagnosed in women who are trying to conceive; therefore, the prognosis of future fertility is one of the main concerns associated with this diagnosis. Management can be surgical, expectant or medical with methotrexate (MTX). However, the best approach is tailored to the woman's individual case. The authors present the case of a primigravida woman presenting with abdominal pain and vaginal bleeding at 6 weeks gestation following assisted reproduction. Her BHCG showed a suboptimal rise. Her TV USS showed no evidence of an intrauterine pregnancy. There was no evidence of an adnexal mass or free fluid. As her BHCG remained static, she underwent a diagnostic laparoscopy. A right sided IEP was identified. Due to the high risk of bleeding requiring transfusion or hysterectomy and her desire to preserve her fertility, she received medical management with MTX. Indeed, research has shown that women successfully managed expectantly achieve better reproductive outcomes, with the shortest time to achieve a subsequent intrauterine pregnancy. This case acts as a cautionary reminder of the challenges associated with identifying an IEP on TV USS. A high index of clinical suspicion is required to prevent maternal morbidity and mortality.

Levator Ani Syndrome Presenting with Vaginal Pain.

Levator ani syndrome (LAS), also known as levator ani spasm, puborectalis syndrome, chronic proctalgia, pyriformis syndrome and pelvic tension myalgia, produces chronic anal pain. The levator ani muscle is susceptible to the development of myofascial pain syndrome, and trigger points may be elicited on physical examination. The pathophysiology remains to be fully delineated. The diagnosis of LAS is suggested primarily by the clinical history, physical examination and the exclusion of organic disease that can produce recurrent or chronic proctalgia. Digital massage, sitz bath, electrogalvanic stimulation and biofeedback are the treatment modalities most frequently described in the literature. Pharmacological management includes non-steroidal anti-inflammatory medications, diazepam, amitriptyline, gabapentin and botulinum toxin. The evaluation of these patients can be challenging due to a diversity of causative factors. The authors present the case of a nulliparous woman in her mid-30s presenting with acute onset of lower abdominal and rectal pain radiating to her vagina. There was no history of trauma, inflammatory bowel disease, anal fissure or altered bowel habit. Each pain episode lasted longer than 20 min and was exacerbated by sitting. Neurological examination showed no evidence of neurological dysfunction. Rectal examination was unremarkable. During vaginal examination, palpation of the levator ani muscles elicited pain indicating pelvic floor dysfunction. Laboratory investigations including a full blood count and C reactive protein were within normal range. Further investigation with a transabdominal ultrasound scan, CT of the abdomen and pelvis and MRI of the lumbar spine were unremarkable. She commenced treatment with amitriptyline 20 mg once daily. She was referred for pelvic floor physiotherapy. Functional pain syndromes, such as LAS, should be regarded as diagnoses of exclusion and considered only after a thorough evaluation has been performed to rule out structural causes of pain. Knowledge of the pelvic floor and pelvic wall muscles may enable the physician to identify LAS, a possible cause of chronic pelvic pain.

Arteriovenous malformation of the small intestine presenting with a transfusion-dependent anaemia in pregnancy.

Gastrointestinal bleeding that originates in the small intestine is often difficult to diagnose. Bleeding from a small intestinal arteriovenous malformation (AVM) is rare, with congenital AVMs more commonly located in the rectum or sigmoid. There is a relative paucity of cases reported in the literature. In the gastrointestinal tract, it can cause acute and chronic bleeding, which can be fatal. Although the incidence of small bowel AVMs is quite low, such lesions can be identified as the bleeding source in patients with obscure gastrointestinal bleeding (OGIB) harbouring severe, transfusion-dependent anaemia. It can be exceedingly difficult to localise and diagnose gastrointestinal tract bleeding, particularly in cases of occult small bowel AVMs. CT angiography and capsule endoscopy can help to establish the diagnosis. Laparoscopy is an appropriate and beneficial treatment modality for small bowel resection. The authors present the case of a primigravida woman in her late 20s diagnosed with a symptomatic transfusion-dependent anaemia during her pregnancy. She developed OGIB and despite no history of chronic liver disease became encephalopathic. Due to her physical deterioration and uncertain diagnosis, her caesarean section was performed at 36+6 weeks to expedite investigations and treatment. She was diagnosed with a jejunal AVM and underwent coiled embolisation of her superior mesenteric artery. She became haemodynamically unstable and underwent a laparotomy and small bowel resection. A full non-invasive liver screen was negative, however, her MRI liver described multiple focal nodular hyperplasia (FNH) lesions raising the possibility of FNH syndrome in the context of a previous AVM malformation. A prompt stepwise, multimodality diagnostic approach is required to prevent patient morbidity and mortality.

Leiomyoma presenting as an anterior vaginal mass.

Leiomyoma, otherwise known as a fibroid, is commonly encountered in the uterus. Vaginal leiomyomas are extremely rare with a relative paucity of cases reported in the literature. Due to the rarity of the disease and complexity of the vaginal anatomy, definitive diagnosis and treatment are challenging. The diagnosis is often only made postoperatively after resection of the mass. They usually arise from the anterior vaginal wall and women may present with dyspareunia, lower abdominal pain, vaginal bleeding or dysuria. Imaging with a transvaginal ultrasound scan and MRI can confirm the vaginal origin of the mass. Surgical excision is the treatment of choice. The diagnosis is confirmed following histological assessment. The authors present the case of a woman in her late 40s presenting to the gynaecology department with an anterior vaginal mass. Further investigation with a non-contrast MRI was suggestive of a vaginal leiomyoma. She underwent surgical excision. Histopathological features were in keeping with the diagnosis of a hydropic leiomyoma. A high index of clinical suspicion is required to establish the diagnosis as it can be mistaken for a cystocele, Skene duct abscess or Bartholin gland cyst. Although it is a benign entity, local recurrence following incomplete resection and sarcomatous changes have been reported.

Reducing MRSA Infection in a New NICU During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) is prevalent in most NICUs, with a high rate of skin colonization and subsequent invasive infections among hospitalized neonates. The effectiveness of interventions designed to reduce MRSA infection in the NICU during the coronavirus disease 2019 (COVID-19) pandemic has not been characterized. METHODS: Using the Institute for Healthcare Improvement's Model for Improvement, we implemented several process-based infection prevention strategies to reduce invasive MRSA infections at our level IV NICU over 24 months. The outcome measure of invasive MRSA infections was tracked monthly utilizing control charts. Process measures focused on environmental disinfection and hospital personnel hygiene were also tracked monthly. The COVID-19 pandemic was an unexpected variable during the implementation of our project. The pandemic led to restricted visitation and heightened staff awareness of the importance of hand hygiene and proper use of personal protective equipment, as well as supply chain shortages, which may have influenced our outcome measure. RESULTS: Invasive MRSA infections were reduced from 0.131 to 0 per 1000 patient days during the initiative. This positive shift was sustained for 30 months, along with a delayed decrease in MRSA colonization rates. Several policy and practice changes regarding personnel hygiene and environmental cleaning likely contributed to this reduction. CONCLUSIONS: Implementation of a multidisciplinary quality improvement initiative aimed at infection prevention strategies led to a significant decrease in invasive MRSA infections in the setting of the COVID-19 pandemic.

Vitamin B12 deficiency presenting with a pancytopenia in pregnancy.

Vitamin B12 deficiency is a significant public health problem globally. Although it is a well-known cause of macrocytic anaemia and in advanced cases, pancytopenia, there remains a relative paucity of cases reported in pregnancy. It is associated with an increased risk of pregnancy complications and adverse birth outcomes such as neural tube defects, preterm birth, low birth weight, neurological sequelae and intrauterine death. It has a predilection for individuals aged >60 years. It has been implicated in a spectrum of neuropsychiatric disorders and it may also exert indirect cardiovascular effects. Severe vitamin B12 deficiency may present with haematological abnormalities that mimic thrombotic microangiopathy such as HELLP syndrome (haemolysis, elevated liver enzymes and low platelets) or it may present as pseudothrombotic microangiopathy (Moschcowitz syndrome) characterised by anaemia, thrombocytopenia and schistocytosis. It can also closely mimic thrombotic thrombocytopenia purpura, hence posing a diagnostic challenge to the unwary physician. Serological measurement of vitamin B12 levels confirms the diagnosis. Oral supplementation with vitamin B12 remains a safe and effective treatment. The authors describe the case of a multiparous woman in her late 20s presenting with a plethora of non-specific symptoms at 29+5 weeks' gestation. Her haemoglobin was 45 g/L, platelets 32×109/L, vitamin B12 <150 ng/L and serum folate <2 µg/L. She was not a vegetarian, but her diet lacked nutrition. Following parenteral B12 supplementation, her haematological parameters improved. The pregnancy was carried to term. Due to the plethora of non-specific symptoms, the diagnosis can be challenging to establish. Adverse maternal or fetal outcomes may occur. Folic acid supplementation may mask an occult vitamin B12 deficiency and further exacerbate or initiate neurological disease.

Ruptured ovarian ectopic pregnancy presenting with an acute abdomen.

An ectopic pregnancy occurs in 2% of all pregnancies. A primary ovarian ectopic (OP) is a rare entity and occurs in <2% of all ectopic gestations. It may present in those individuals who take ovulatory drugs, use an intrauterine device or have undergone in vitro fertilisation or embryo transfer. Multiparity and a younger age are other recognised risk factors. Diagnosing an OP pregnancy remains a challenge and it may be misdiagnosed as a bleeding luteal cyst, a haemorrhagic ovarian cyst or a tubal pregnancy by ultrasound scan. The diagnosis is often only established at laparoscopy following histopathological examination. A ruptured OP is a potentially life-threatening condition due to its potential for haemorrhage and hemodynamic collapse. Hence, early diagnosis is crucial to prevent serious morbidity and mortality. The authors present the case of a multiparous woman in her late 30s presenting with a seizure and lower abdominal pain at 6 weeks gestation. Her beta human chorionic gonadotropin was >9000 Miu/mL. A transvaginal ultrasound scan showed no evidence of an intrauterine pregnancy. There was free fluid in the pelvis. She was hemodynamically stable. She underwent a diagnostic laparoscopy, which showed hemoperitoneum and a ruptured left OP pregnancy. She underwent a left oophorectomy. Histology confirmed chorionic villi within the ovarian stroma. This case demonstrates the challenges in preoperative diagnosis of a ruptured OP pregnancy and acts as a cautionary reminder that individuals can present with hemodynamic stability. Rarely, as in this case, an OP pregnancy can occur without the presence of risk factors. Despite its rarity, a ruptured OP pregnancy should be considered in the differential diagnosis of women of reproductive age presenting to the emergency department with acute abdominal pain and a positive pregnancy test.

Maternal sepsis caused by Listeria monocytogenes with a fatal fetal outcome.

Improving maternal and child health is a global priority. Although infection with Listeria monocytogenes (LM), a small facultative anaerobic, gram-positive motile bacillus is rare, when it infects the maternal-fetoplacental unit, it can result in adverse fetal sequelae such as chorioamnionitis, preterm labour, neonatal sepsis, meningitis and neonatal death. Pregnancy-associated listeriosis may present with a plethora of diverse, non-specific symptoms such as fever, influenza-like or gastrointestinal symptoms, premature contractions and preterm labour. It has a predilection for the second and third trimester of pregnancy, occurring sporadically or as part of an outbreak, most of which have involved unpasteurised dairy products, long shelf life products, contaminated ready-to-eat food, deli meats and soft cheeses. Strains belonging to the clonal complexes 1, 4 and 6 are hypervigilant and are commonly associated with maternal-neonatal infections. Maternal listeriosis occurs as a direct consequence of LM-specific placental tropism, which is mediated by the conjugated action of internalin A and internalin B at the placental barrier. The diagnosis is established from placental culture. Penicillin, ampicillin and amoxicillin are the antimicrobials of choice. It has a high fetal morbidity of up to 30%. The authors present the case of a multiparous woman in her early 20s presenting with sepsis and preterm premature rupture of her membranes at 21 weeks gestation. A live baby was delivered spontaneously and died shortly after birth. Placental cultures and postmortem examination were consistent with the diagnosis of disseminated Listeria infection. Due to the increased susceptibility of pregnant women for LM, a high index of clinical suspicion is required to establish the diagnosis and initiate appropriate antimicrobial therapy to reduce adverse fetal outcomes.

Caecal endometriosis presenting with an acute abdomen in pregnancy.

Endometriosis is defined as the presence of endometrial tissue outside the uterus, which induces a chronic inflammatory response. Its prevalence remains unknown, but it has been estimated to affect up to 10% of women of reproductive age. Although it is a benign oestrogen-dependent gynaecological condition, women may describe painful symptoms such as cyclical pelvic pain, dysmenorrhoea and dyschezia. Intestinal endometriosis may affect the ileum, appendix, sigmoid colon and rectum. It may present with a myriad of symptoms such as abdominal pain, vomiting, diarrhoea, constipation and haematochezia. Caecal endometriosis can present as an acute appendicitis, making the diagnosis challenging to establish in pregnancy. Transmural involvement and acute occlusion are very rare events. The gold standard for diagnosis remains laparoscopy with tissue sampling for histological confirmation. Although endometriosis improves during pregnancy under the effect of progesterone, the ectopic endometrium becomes decidualised with a progressive reduction in size. The authors present the case of a multiparous woman in her mid-30s with acute onset of right-sided abdominal pain at 35 weeks gestation. Physical examination was suggestive of an acute appendicitis and MRI showed an inflamed caecum. She became acutely unwell requiring an emergency caesarean section. A mass in the caecum was observed with impending perforation at the caecal pole. A right hemicolectomy was performed. Histopathological examination confirmed the diagnosis of endometriosis with decidualisation. Although endometriosis improves during pregnancy, this case shows the unexpected complications of the disease and demonstrates the importance of considering endometriosis in the differential diagnosis of an acute abdomen in women of childbearing age to prevent maternal morbidity and fetal loss.

Ruptured chronic ectopic pregnancy presenting with a negative urine pregnancy test.

An acute ectopic pregnancy is one of the most common gynaecological emergencies in clinical practice. The diagnosis is usually established by a combination of clinical examination findings, correlated with sonographic and laboratory results. However, a chronic ectopic pregnancy (CEP) may occur when the ectopically implanted gestation, mostly in the fallopian tubes, invades the underlying structures, causing protracted destruction at the site of implantation. Individuals may present with subacute or chronic abdominal pain, abnormal vaginal bleeding, amenorrhoea and a low bHCG. The correct diagnosis is often only established following laparoscopy or even histologically after the operation. The authors present the case of a woman in her 30 s presenting with severe right sided abdominal pain and a failing pregnancy at 10 weeks gestation. Her urine pregnancy test was negative, but her serum bHCG was 18 IU/L. A transvaginal ultrasound scan confirmed a ruptured right tubal ectopic pregnancy. A laparoscopic salpingectomy was performed. This case provides an important reminder that a CEP should always be considered in the differential diagnosis of women of reproductive age presenting with acute lower abdominal pain, despite a negative urine pregnancy test.

Robert's uterus (asymmetric septate uterus): a rare congenital Müllerian duct anomaly.

Müllerian anomalies such as Robert's uterus, which was first described by the French gynaecologist Dr Helene Robert in 1969, are rare clinical entities and have been reported in <3% of the female population. Robert's uterus is a rare phenomenon with a relative dearth of reported cases. Affected individuals may present with pelvic pain and dysmenorrhoea that intensifies near menses or acutely, with severe abdominal pain to the emergency department. They are also associated with adverse pregnancy outcomes, abnormal fetal presentation, preterm labour, recurrent pregnancy loss and infertility. Although ultrasound has a role in its initial assessment, MRI is the best modality to further delineate its anatomy. It is typically managed via laparotomy and total horn resection, endometrectomy of the blind cavity or abdominal metroplasty. The authors present the case of a 40-year-old woman at 19+3 weeks gestation with acute onset of left-sided abdominal pain. A transvaginal ultrasound and MRI of the pelvis confirmed a Robert's uterus with a viable pregnancy in the upper left horn. She developed a ruptured horn with significant haemoperitoneum. An emergency laparotomy was performed and a non-viable fetus was evident. Only a few cases of pregnancy in the blind hemicavity have been reported so far. This case also highlights the importance of considering this diagnosis in young females presenting with dysmenorrhoea and normal menstrual flow. It is imperative to render a prompt diagnosis, as minimally invasive procedures may be more effective if detected before the formation of adnexal endometriomas.

Posterior reversible encephalopathy syndrome in the puerperium: a case report.

Headache is a common presentation to the physician. Although most causes of a headache in pregnancy are benign, the pregnant woman is at risk of a life-threatening secondary headache such as eclampsia, venous sinus thrombosis or posterior reversible encephalopathy syndrome (PRES). Pregnancy and the puerperium are prothrombotic risk factors. Although the aetiology of PRES remains to be fully elucidated, hypertension with failed autoregulation results in brain oedema. An alternative hypothesis includes endothelial injury and hypoperfusion leading to an alteration in the integrity of the blood-brain barrier. It occurs in complex, systemic conditions such as pre-eclampsia, following bone marrow transplantation, chemotherapy, sepsis and autoimmune diseases. The most common clinical presentation is headache, altered alertness, seizures and visual disturbance such as hemianopia, visual neglect and cortical blindness. It can also develop in normotensive individuals. Symmetric vasogenic oedema in a watershed distribution involving the parieto-occipital regions are typically evident on MRI. Management is determined by the underlying aetiological risk factor. The authors present the case of a 32-year-old multiparous woman presenting with tonic-clonic seizures 16 days following an elective caesarean section. Her pregnancy was complicated by hypertension and headache. There was no history of pre-eclampsia. She required intubation and ventilation. The diagnosis of PRES was established on MRI. Early recognition and treatment provide a favourable prognosis as the clinical symptoms and imaging characteristics are reversible in a large cohort of affected individuals.

Uterine leiomyosarcoma: a rare clinical entity.

Leiomyosarcoma is a rare aggressive malignant mesenchymal tumour, accounting for 1% of all uterine malignancies. It spreads rapidly through the intraperitoneal and haematogenous pathways. It is often diagnosed postoperatively following myomectomy, hysterectomy or supracervical hysterectomy for presumed benign disease. It has a predilection for perimenopausal women with a median age of 50 years. Individuals may describe symptoms of vaginal or abdominal pressure. Physical examination may reveal a large palpable pelvic mass, which may haemorrhage. Surgery remains the mainstay of treatment. Hysterectomy and a bilateral salpingo-oophorectomy may be considered, depending on the individual's menopausal status. Ovarian preservation can be considered in young patients. Adjuvant systemic treatment and radiotherapy are of no benefit. Gemcitabine/docetaxel and doxorubicin have shown benefit in the treatment of advanced or recurrent disease. The authors present the case of a 44-year-old woman with lower abdominal pain, vaginal bleeding and a uterine fibroid. Laboratory investigations confirmed a leucocytosis, neutrophilia and a thrombocythaemia. Further investigation with an MRI pelvis showed a very large, heterogeneous, malignant appearing pelvic mass compressing the right ureter and it appeared uterine in nature. Her staging CT showed multiple lung metastases. The diagnosis of uterine leiomyosarcoma was subsequently established. Due to the aggressive behaviour of this sarcoma subtype, novel early detection strategies and targeted therapies are required.

Ovarian vein thrombosis in the postnatal period.

Although ovarian vein thrombosis (OVT) is classically considered a puerperal pathology, it can also occur in nonpuerperal settings such as endometritis, pelvic inflammatory disease, Crohn's disease, pelvic or gynaecological surgeries and thrombophilia. Hypercoagulation conditions such as antiphospholipid syndrome, systemic lupus erythematosus, factor V Leiden and protein C and S deficiency are all recognised risk factors. It is also a known complication during pregnancy often presenting with fever and lower abdominal pain within weeks after delivery. Its incidence is exceedingly rare, occurring in 0.05% of all pregnancies that result in live births and peaking around 2-6 days after delivery. Its preferential involvement of the right ovarian vein may be explained by the compression of the inferior vena cava and the right ovarian vein due to dextrorotation of the uterus during pregnancy. Furthermore, antegrade flow of blood and multiple incompetent valves in the right ovarian vein favours bacterial infection. Complications may include sepsis and thrombus extension to the inferior vena cava or left renal vein and rarely, pulmonary embolism. The authors present the case of a 27-year-old woman with lower abdominal pain 5 weeks after an elective caesarean section. Although the diagnosis of postpartum endometritis was initially considered, a CT suggested a right OVT. She commenced treatment with low-molecular weight heparin. A high index of clinical suspicion is required in order to establish the diagnosis of this rare cause of abdominal pain, which can mimic an acute abdomen.

Mixed dementia and hyperactive delirium: a diagnostic challenge.

It is well recognised that acute confusion or delirium complicates up to 10% of acute medical admissions. Disorientation in time and place with an impaired short-term memory and conscious level are the hallmarks of an acute confusion. In delirium, disorders of perception may produce restlessness and agitation. A similar state during the final days of life is termed 'terminal delirium'. Less than 10% of affected individuals will have a primary neurological disorder, for example, dementia, a neurodegenerative disease with varying aetiologies. Currently there are at least 50 million people globally suffering from dementia rendering it a global healthcare problem. Mixed dementia (MD) can be defined as a cognitive decline sufficient to impair independent functioning in daily life resulting from the coexistence of Alzheimer's disease (AD) and cerebrovascular pathology. MD occurs in patients with a neurodegenerative disorder, such as AD, Lewy body or Pick's disease and additionally cerebrovascular disease. The mechanistic synergisms between the coexisting pathologies affecting dementia risk, progression and the ultimate clinical manifestations remain elusive. Although AD can be diagnosed with a considerable degree of accuracy, the distinction between isolated AD, vascular dementia and MD, when both pathologies coexist in the same patient remains one of the most difficult diagnostic challenges because their clinical presentation can overlap. Neuropathological studies indicate that mixed vascular Alzheimer's dementia (MD) has a prevalence of 22% in the elderly. The authors present the case of a 78-year-old man with a diagnosis of MD presenting to the emergency department with delirium, a common but serious acute neuropsychiatric syndrome with the core features of inattention and global cognitive dysfunction. This case demonstrates the challenges in establishing a diagnosis in patients presenting with MD and shows that a cognitive assessment at presentation in a delirious state offers very little diagnostic information. It is therefore suggested to conduct a routine cognitive function examination on patients with dementia to anticipate new neurological signs and/or symptoms thus allowing earlier diagnosis and treatment. However, a baseline cognitive assessment when the patient was well, duration and nature of deterioration as well as collateral history will help differentiate delirium from an underlying dementia.

Pontine stroke mimicking Bell's palsy: a cautionary tale!

Stroke has been called apoplexy since the ancient times of Babylonia. Johann Jakob Wepfer, a Swiss physician, first described the aetiology, clinical features, pathogenesis and postmortem features of an intracranial haemorrhage in 1655. Haemorrhagic and ischaemic strokes are the two subtypes of stroke. Bell's palsy usually presents with an isolated facial nerve palsy. A lacunar infarct involving the lower pons is a rare cause of solitary infranuclear facial paralysis. The authors present the case of a 66-year-old woman presenting with a 3-day history of headache, vertigo, nausea, vomiting and facial weakness. Her comorbidities included diabetes, hypertension and hypercholesterolaemia. It was challenging to identify the pontine infarct on MRI due to its small size and the confounding presentation of complete hemi-facial paralysis mimicking Bell's palsy. Our case provides a cautionary reminder that an isolated facial palsy should not always be attributed to Bell's palsy, but can be a presentation of a rare dorsal pontine infarct as observed in our case. Anatomic knowledge is crucial for clinical localisation and correlation.

Vaginal foreign body insertion in a patient with emotionally unstable personality disorder.

Insertion of foreign objects into one or more bodily orifice, otherwise known as polyembolokoilamania, occurs as a result of a variety of psychosocial and psychiatric states. Such behaviour exposes the affected individual to the complications of object insertion, surgical removal and its adverse sequelae such as a colovesical fistula. Foreign body insertion into the vagina mainly involves children and can be associated with premenarchal vaginal discharge or sexual abuse. The gynaecological literature describes cases involving adults and can be associated with drug smuggling or sexual gratification. Commonly retrieved foreign bodies from the vagina includes tampons, hair pins, buttons, seeds, toy parts, objects used in foreplay, forgotten pessaries, pen caps, toilet tissue and illicit drugs for trafficking. There is a relative dearth of cases reported in the psychiatric literature. Management of deliberate foreign body insertion [DFBI) in borderline personality disorder patients is challenging, often repetitive and the potential for further self-harm and complex emotional issues may elicit strong countertransference from medical staff. Although there are well-established guidelines for acute medical and surgical management of DFBI, none provide an overview of the management of repeat presentations or consider the role of secondary gain or provide reinforcement strategies for managing this complex patient cohort. The authors present the case of a 23-year-old woman with an emotionally unstable personality disorder presenting to the emergency department after inserting objects in her vagina. This paper will provide an overview of the presentation, investigations and management of individuals presenting after inserting foreign objects into the vagina. In the majority of cases, a carefully obtained history and physical examination will render the diagnosis, although imaging modalities may be required to locate the misplaced objects. Individuals may present with bleeding, blood stained or foul-smelling vaginal discharge. Prompt management can prevent morbidity and mortality resulting from complications.