ABSTRACT
There are more than 150,000 new cases of coccidioidomycosis annually in the United States and the incidence is increasing. Although the majority of cases result in mild or no symptoms, pregnancy is a risk factor for complicated and disseminated disease. Overall, coccidioidomycosis is rare in pregnancy and there have been few reports in the literature of dissemination into the placenta. This report describes a 31-year-old primigravida with coccidioidomycosis diagnosed by placental examination. In retrospect, she had mild symptoms in the antepartum period but otherwise had no immediate complications due to the infection apart from the adhesive pelvic disease. The clinician should have a high index of suspicion for coccidioidomycosis in a pregnant woman presenting with a persistent respiratory illness who resides in, or who has recently recent travelled to, an endemic area. Additionally, a diagnosis of disseminated coccidioidomycosis should be considered for a woman with adhesive pelvic disease residing in an endemic region and one should consider microscopic placental examination if these findings are noted at cesarean delivery.
ABSTRACT
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.
ABSTRACT
Introduction. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is a relatively uncommon but traumatic condition occurring in the later stage of pregnancy as a complication of severe preeclampsia or eclampsia. Prompt brain computed tomography (CT) or magnetic resonance imaging (MRI) and a multidisciplinary management approach are required to improve perinatal outcome. Case. A 37-year-old, Gravida 6, Para 1-0-4-1, Hispanic female with a history of chronic hypertension presented at 26 weeks and 6 days of gestational age. She was noted to have hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome accompanied by fetal growth restriction (FGR), during ultrasound evaluation, warranting premature delivery. The infant was delivered in stable condition suffering no permanent neurological deficit. Conclusion. HELLP syndrome is an uncommon and traumatic obstetric event which can lead to neurological deficits if not managed in a responsive and rapid manner. The central aggravating factor seems to be hypertension induced preeclamptic or eclamptic episode and complications thereof. The syndrome itself is manifested by hemolytic anemia, increased liver enzymes, and decreasing platelet counts with a majority of neurological defects resulting from hemorrhagic stroke or subarachnoid hemorrhage (SAH). To minimize adverse perinatal outcomes, obstetric management of this medical complication must include rapid clinical assessment, diagnostic examination, and neurosurgery consultation.
