Retained Intrauterine Device (IUD): Triple Case Report and Review of the Literature.

BACKGROUND: Throughout the world, intrauterine contraceptive devices (IUDs) are a frequently used, reversible, popular contraceptive method. They are usually placed without major complications. Uterine perforation is a rarely observed complication. Migration of the IUD to the pelvic/abdominal cavity or adjacent structures can occur after perforation. We present 3 cases of uterine perforation, possibly due to scarred myometrium associated with a cesarean delivery. We describe 3 perforations with IUDs lodged in the bladder serosa, the posterior cul-de-sac, and tissue adjacent to the cardinal ligament and external iliac artery. CASES: Case 1. 26-year-old, Gravid 4, Para 2113, nonpregnant female with a history of a cesarean delivery underwent placement of an IUD one year after an elective pregnancy termination, presenting with abdominal pain requesting removal of the IUD. On speculum, although the IUD strings were visualized, the IUD could not be removed. Sonogram imaging identified an empty endometrial cavity with the IUD in posterior cul-de-sac. The IUD was removed via laparoscopy. CASE 2: 34-year-old Gravida 5, Para 4004, at 27 weeks and 3 days gestation, female with history of two previous cesarean deliveries underwent a third cesarean after spontaneous rupture of membranes with comorbid chorioamnionitis. Reproductive history was significant for placement of an IUD that had not been removed or imaged during obstetrical sonograms. The clinical evaluation revealed that the IUD had been spontaneously expelled. On the fifth operative day, the patient is febrile with CT demonstrating the IUD penetrating the anterior surface of bladder. On cystoscopy the bladder mucosa was intact. The IUD was removed via laparotomy with repair of the bladder, serosa, and muscular layer. CASE 3: 26-year-old, Gravid 4, P3013, nonpregnant female with three previous Cesarean deliveries had an IUD in place. However, with the IUD in situ, the patient conceived and had a spontaneous abortion. After the spontaneous abortion, she presented to clinic to have the IUD removed due to pain that was present since placement. Although the IUD strings were visualized, attempts to remove it were unsuccessful. Imaging identified the IUD outside the uterine cavity. Palpation with a blunt probe laparoscopically revealed a hard object within the adhesion band, close to the cardinal ligament. As per radiology evaluation, IUD was embedded 1cm from the external iliac artery on the right side outside the uterus in the adnexal region. A multidisciplinary procedure with gynecologic-oncologist was scheduled for removal due to the high risk of perioperative bleeding. CONCLUSION: Patients in whom uterine perforation and IUD migration are suspected should have appropriate evaluation that includes transvaginal or transabdominal ultrasound or radiographs to confirm the position of the IUD, regardless of whether they are asymptomatic or present with symptoms. It is particularly important in the presence of a scarred uterus that imaging is used to identify the location of a missing IUD. The uterine scar of a cesarean may facilitate migration of the IUD. Cross sectional imaging, such as CT or MRI scan, may be needed to rule out adjacent organ involvement before surgical removal.

Prevalence and predictors of positive screening for postpartum depression in minority parturients in the South Bronx.

It is reported that the rates of perinatal depressive disorders are high in ethnic minority groups from non-English speaking countries. However, very few studies have compared the prevalence of positive screening for postpartum depression (PPD) in minority communities living in an inner city. The goal of this study is to determine the prevalence and the predictors of positive screening for postpartum depression in minority parturients in the South Bronx. The study is a chart review of 314 minority parturients, Black or Hispanic, screened for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) tool. The overall prevalence of a positive EPDS screen among Black and Hispanic women was similar, 24.04 and 18.75%, respectively. The Black immigrant cohort had comparable positive screens with 23.81 as African Americans. Hispanic women born in the USA had the least prevalence of positive screens, 7.14%, and those who moved from the Dominican Republic and Puerto Rico had a prevalence of 17.24% of positive screens. The women who immigrated from Mexico, Central America, or South America had the highest prevalence of positive screens for PPD, 32.26%. As to the socioeconomic status (SES), there was a significant increase of 27.04 vs. 13.95% (P < 0.019) in positive screens for PPD for the unemployed mothers. Overall, Black and Hispanic parturients had similar rates of positive screens for PPD. Among the Hispanic women, immigrants had higher rates of positive screens, with those from Mexico, Central, and South America as the highest. The hospital experience did not affect the rates of positive screens. Neither did the SES with one exception; those unemployed had the higher rates of positive screens.

Gestational Gigantomastia Complicating Pregnancy: A Case Report and Review of the Literature.

Background. Gestational gigantomastia is a rare disorder without clear etiology or well-established risk factors. Several pathogenic mechanisms contributing to the disease process have been proposed, all of which can lead to a similar phenotype of breast hypertrophy. Case. A 28-year-old Guinean woman presented at 37 weeks of gestation with bilateral gigantomastia, mastalgia, peau d'orange, and back pain. Prolactin levels were 103.3 µg/L (with a normal reference value for prolactin in pregnancy being 36-372 µg/L). The patient was treated with bromocriptine (2.5 mg twice daily), scheduled for a repeat cesarean, and referred to surgery for bilateral mammoplasty. Conclusion. Gestational gigantomastia is a rare disorder, characterized by enlargement and hypertrophy of breast tissue. Our patient presented with no endocrine or hematological abnormalities, adding to a review of the literature for differential diagnoses, workup, and management of cases of gestational gigantomastia with normal hormone levels.

Primum non nocere: how active management became modus operandi for intrahepatic cholestasis of pregnancy.

The Royal College of Obstetrics and Gynecology does not endorse routine active management of intrahepatic cholestasis of pregnancy (ICP)-affected pregnancies. In contrast, the American College of Obstetricians and Gynecologists supports active management protocols for ICP. To investigate this controversy, we evaluated the evidence supporting ICP as a medical indication for early term delivery and the evolution of active management protocols for ICP. Sixteen articles published between 1986 and 2011 were identified. We created 2 groups based on whether obstetric care included active management. Group 1 comprised 6 uncontrolled reports without active management that were published between 1967 and 1983 that described high perinatal mortality rates that primarily were related to prematurity sequel. This group became the fundamental 'core' evidence for ICP-associated stillbirths and by extrapolation justification for active management. Group 2 was comprised of 10 reports in which the authors credited empirically adopted active management with the observed low stillbirth rates in ICP-affected pregnancies. Although the group 1 articles routinely are cited as evidence of ICP-associated stillbirth risk, the 1.2% stillbirth rate (4/331) in this group is similar to the background stillbirth rates of 1.1% (11/1000) and 0.6% (6/1000) in 1967 and 2011, respectively (P = .062 and P = .0614, respectively). Likewise, the stillbirth rates for articles in group 2 were similar to their respective national stillbirth rate. Nevertheless, group 2 articles have become the evidence-based support for active management. We found no evidence to support the practice of active management for ICP.

Evaluation of B-type natriuretic peptide levels in singleton hypertensive minority women.

OBJECTIVE: To determine the pattern of the B-type natriuretic peptide (BNP) levels in minority women presenting with elevated blood pressure during pregnancy. STUDY DESIGN: A review of 503 charts was undertaken, in sequence, of pregnant women who presented to the service with elevated blood pressure or had been referred there for suspected hypertension. Serum BNP levels had been obtained and other diagnostic procedures performed. Ultimately 283 women were determined not to meet the criteria for hypertension or were normotensive. A total of 110 patients met the criteria for gestational hypertension, and 68 patients met the criteria for preeclampsia. RESULTS: There were no differences in BNP levels among women of Hispanic and of African heritage in each category. BNP levels were significantly higher in women in the preeclamptic group, whether of African or Hispanic heritage. The negative predictive values for women with preeclampsia were 87.04% for women of African heritage and 96.38% for women of Hispanic origin. CONCLUSION: No differences in BNP levels were found among minority women of African or Hispanic descent. Serum BNP levels provide useful information for the clinical evaluation and management of singleton patients presenting to triage hypertensive after 20 weeks of pregnancy.

Predicting survival of periviable fetuses using NICHD fetal heart rate categories.

OBJECTIVE: To evaluate whether National Institute of Child Health and Human Health and Development (NICHD) fetal heart rate categories were predictive of neonatal survival in periviable pregnancies. METHODS: We reviewed the charts of 57 infants delivered at 23 and 24 weeks' gestation. Fetal heart rate tracings were evaluated following the NICHD 2008 criteria, using the acceleration height of 10 bpm and duration of 10 s. Multiple logistic regression analyses were performed using survival, fetal morbidities, and cord pH <7.1 as dependent variables. Independent variables included fetal heart rate category, mode of delivery, resuscitation, and histological chorioamnionitis. Outcomes of infants delivered at 23 and 24 weeks were also compared. RESULTS: In 23-week pregnancies, fetal heart rate category 2 was associated with improved short-term survival compared to category 3 (OR 1.3, 95% CI 0.11-15.7). Cesarean delivery and histological chorioamnionitis were not predictive of survival [(OR 0.5, 95% CI 0.04-7.1, and OR 0.4, 95% CI 0.02-6.85), respectively]. Long-term survival for infants born at 23 and 24 weeks was 8% and 56%, respectively. CONCLUSIONS: The NICHD fetal heart rate category during labor may be associated with survival for infants born at 23 and 24 weeks of gestation. Cesarean delivery was not associated with improved survival.

Serum inhibin A concentration in women with polycystic ovarian syndrome and the correlation to ethnicity, androgens and insulin resistance.

A prospective case-series in an academic hospital clinic was performed to determine whether there is a relationship between polycystic ovarian syndrome (PCOS) and ethnicity. Also, serum inhibin A concentrations were compared between PCOS and normal-ovulatory women. The possibility of a correlation between inhibin A, androgens and insulin resistance in PCOS women was evaluated. Serum inhibin A concentrations were measured in anovulatory PCOS patients (n=32) and in control women of reproductive age (n=16). Statistical analysis was performed using the Mann-Whitney U-test. Serum concentrations of inhibin A, follicle-stimulating hormone, LH, prolactin, thyroid-stimulating hormone, fasting glucose, insulin, testosterone, 17-hydroxyprogesterone (17-OHP) and dehydroepiandrosterone sulphate (DHEAS) were measured. Inhibin A concentrations were significantly lower (4.5+/-4.8 pg/ml) when compared with the control group (13.2+/-14.4 pg/ml; P=0.003) and were not significantly different between Hispanic and Caucasian women diagnosed with PCOS. There was no correlation between inhibin A concentrations and insulin, testosterone, free testosterone, 17-OHP, or DHEAS concentrations. In PCOS women, inhibin A concentrations are similar between Hispanic and Caucasian women; however, women with PCOS, regardless of ethnicity, have a lower inhibin A concentration compared with normal-ovulatory women. No correlation was observed between inhibin A androgens and insulin resistance in women diagnosed with PCOS.

Association of preeclampsia and myasthenia: a case report.

BACKGROUND: Myasthenia gravis in pregnancy is uncommon, and its occurrence in conjunction with preeclampsia is very rare but may be catastrophic for mother and child. CASE: A 31-year-old, multiparous woman, with a history of myasthenia gravis and thymectomy, presented at 27 weeks with worsening preeclampsia and delivered by cesarean section under spinal anesthesia. Preeclamptic crisis with hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome developed postpartum. Blood pressures remained severely high. Intensive care management and a labetalol drip resolved the crisis. CONCLUSION: Added complications may arise from myasthenic exacerbation, difficulties in early recognition of signs and symptoms, and the use of medications that slow neuromuscular transmission.

A new obstetrical polyurethane versus stainless steel forceps: a comparison of forces generated to the base of the fetal skull during simulated deliveries.

BACKGROUND: Decreasing the maximum force applied during traction to the base of the fetal skull using a less rigid polyurethane forceps is the basis of this study. Our hypothesis was that less force would be generated with polyurethane forceps than with steel forceps. OBJECTIVE: To test a new soft polyurethane obstetrical forceps for maximal force generated to the base of the skull during simulated occiput anterior deliveries and to compare this to a similar shaped steel forceps. METHODS: After designing a prototype polyurethane forceps, we used a pelvic manikin model and a fetal manikin model. Force and load sensors were attached at the inner tips of the distal forceps blade. A Tekscan 201 (accurate for measuring 0-25 pounds of force) 0.0008 inches flexible printed circuit was used that measured contact forces. Forceps with an attached calibrated sensor were applied to the fetal head while inside the pelvic model. RESULTS: The median maximum traction force at the base of the fetal skull was 4.60 pounds (range 4.3-4.62) for polyurethane forceps vs. 9.52 pounds (range 9.22-9.52) for steel forceps (P=0.027). CONCLUSION: The polyurethane forceps applied 50% less overall mechanical force than the steel forceps at the tip of the forceps and base of the skull during simulated occiput anterior outlet deliveries.

Inhibin A: marker for diagnosis of ectopic and early abnormal pregnancies.

A prospective case-control study was performed to determine whether inhibin A concentration is a clinically useful marker of ectopic pregnancy (EP). Inhibin A concentration in patients diagnosed with EP by laparoscopic and pathological findings (n = 17) was compared with that in missed miscarriage (n = 35), incomplete miscarriage (n = 14), spontaneous miscarriage (n = 5), threatened miscarriage (n = 6), normal pregnancy (n = 24) and non-pregnant controls (n = 20). The data were analysed using the Mann-Whitney U-test. EP yielded significantly lower inhibin A concentrations compared with normal pregnancy, 12.7 +/- 11.7 versus 237.3 +/- 125.9 pg/ml (P < 0.0002), and similar concentrations to non-pregnant controls (13.3 +/- 14.3 pg/ml). Inhibin A concentrations in abnormal pregnancies were significantly lower than in the normal pregnancy group: missed miscarriage 42.4 +/- 54.9 pg/ml (P < 0.0002); spontaneous miscarriage 47.5 +/- 55.6 pg/ml (P < 0.0002); and incomplete miscarriage 12.2 +/- 10.5 pg/ml (P < 0.0002). Threatened miscarriage was not statistically different to normal pregnancy (183.1 +/- 119.4 pg/ml). Human chorionic gonadotrophin concentrations in EP were not statistically significantly different compared with missed miscarriage and incomplete miscarriage. In conclusion, serum inhibin A concentration may be a reliable marker of EP.