Rare Pediatric Cecal Anomalies: A Lesson in Pediatric Surgery.

BACKGROUND: Rare incidence cases are part of the routine work of pediatric surgeons. Cecal anomalies in children are an example of such cases. Objectives: To describe the presentation, workup, management and outcome of rare cecal anomalies in children and to analyze the skills needed for their successful treatment. METHODS: A retrospective chart review was conducted of all cases of cecal anomalies managed by the pediatric surgical service at a tertiary hospital from June 2017 to January 2020. Data regarding demographics, clinical presentation, radiological studies, surgical treatment, pathology, complications, and outcome were collected. RESULTS: Five cases of cecal anomalies were encountered over a period of 32 months, including a cecal volvulus, cecal duplication, cecal intussusception, and two cecal masses (one ulcerated lipoma and one polyp). All patients, except the patient with cecal duplication, presented acutely and were managed surgically. Long-term follow-up of 17-24 months was unremarkable in all cases. CONCLUSIONS: A wide knowledge base, careful judgment, and creativity enable pediatric surgeons to successfully treat rare conditions such as rare cecal anomalies. These skills should be part of the education of pediatric surgery trainees.

Natural Progression of Helicobacter pylori-Negative Gastritis with Lymphoid Follicles in Children: Prospective Evaluation and Outcome.

BACKGROUND: The association of Helicobacter pylori-negative gastritis with lymphoid follicles (LFs) in children is still unclear. Therefore, we aimed to investigate the natural history and significance of H. pylori-negative gastritis with LFs in children. METHODS: We identified children with histologically proven H. pylori-negative gastritis with LFs between June 2014 and January 2017. The children were invited for a follow-up examination. The clinical, endoscopic, and histological findings of the index esophagogastroduodenoscopy (EGD) were revised and compared to the follow-up findings. RESULTS: A total of 754 children underwent EGD. Among the 48 children diagnosed with H. pylori-negative gastritis, 17 (35.41%) had gastric LFs. Eight agreed to participate in the study. The mean follow-up was 25.58 ± 4.52 (range, 20.53-35.73) months. Three children still had histologic findings of chronic gastritis with LFs. Four children had resolution of the gastritis but still had LFs, and 1 patient had resolution of both the gastritis and LFs. CONCLUSION: LFs were still present in children with H. pylori-negative gastritis after a mean follow-up of 2 years, and in some children, despite resolution of the gastritis. Therefore, this histological finding might be a non-pathological feature in children and does not need any contribution or follow-up.

Characterizing excised breast masses in children and adolescents-Can a more aggressive pathology be predicted?

PURPOSE: Our aim was to characterize excised breast masses in children and adolescent and to identify factors associated with a more aggressive pathology. METHODS: Retrospective review of all female patients <19 who underwent excision of breast masses at our institution between 1999 and 2018. Demographic, clinical, imaging, pathological and management data were collected. We assessed possible association of any of the variables with a more aggressive pathology (phyllodes tumor and malignancy). Correlation between core needle biopsy results and final pathology results was also calculated. RESULTS: 70 patients were included. Median age was 17 years (range: 11-19). Resected mass size was 4 cm (range: 2-16). Final pathology results were: fibroadenoma (49), juvenile fibroadenoma (7), hamartoma (5), benign phyllodes (7), malignant phyllodes (1) and sarcoma (1). Pathology was benign in 61 (87%) patients and more aggressive (phyllodes and sarcoma) in 9 (13%). None of the tested variables was associated with a more aggressive pathology. Presurgical core biopsy results matched final pathology in only 63.6%. CONCLUSIONS: Excised breast masses in children and adolescents are sometimes of a more aggressive pathology, which cannot be predicted by presurgical factors, including a core needle biopsy. Prognosis study LEVEL OF EVIDENCE: III.

Lymphoid follicles in children with Helicobacter pylori-negative gastritis.

PURPOSE: The prevalence of Helicobacter pylori gastritis has been declining, whereas H. pylori-negative gastritis has become more common. We evaluated chronic gastritis in children with regard to H. pylori status and celiac disease (CD). PATIENTS AND METHODS: Demographic, clinical, endoscopic, and histologic features of children who underwent elective esophagogastroduodenoscopy were reviewed retrospectively. Gastric biopsies from the antrum and corpus of the stomach were graded using the Updated Sydney System. H. pylori presence was defined by hematoxylin and eosin, Giemsa, or immunohistochemical staining and urease testing. RESULTS: A total of 184 children (61.9% female) met the study criteria with a mean age of 10 years. A total of 122 (66.3%) patients had chronic gastritis; 74 (60.7%) were H. pylori-negative. Children with H. pylori-negative gastritis were younger (p=0.003), were less likely to present with abdominal pain (p=0.02), and were mostly of non-Arabic origin (p=0.011). Nodular gastritis was found to be less prevalent in H. pylori-negative gastritis (6.8%) compared with H. pylori-positive gastritis (35.4%, p<0.001). The grade of mononuclear infiltrates and neutrophil density was more severe in the H. pylori-positive group (p<0.001). Pan-gastritis and lymphoid follicles were associated most commonly with H. pylori. Although less typical, lymphoid follicles were demonstrated in 51.3% of H. pylori-negative patients. The presence or absence of CD was not associated with histologic findings in H. pylori-negative gastritis. CONCLUSION: Our findings suggest that lymphoid follicles are a feature of H. pylori-negative gastritis in children independent of their CD status.

Role of collagen type IV in the pathogenesis of increased prenasal thickness in Down syndrome fetuses: sonographic and immunohistological findings.

OBJECTIVE: The present study aims to compare the presence and localization of collagen type IV in the prenasal tissue of fetuses with and without Down syndrome (DS). METHODS: Products of conception were obtained from mid-gestation uterine evacuations of 14 DS fetuses and 15 unaffected controls. Microdissection of the prenasal area and an analysis of the prenasal tissue specimens were performed by a single pathologist, blinded to the karyotype results. Immunohistological presence and localization of type IV collagen were analyzed in the basement membrane (BM), blood vessels, and stroma of the tissues. RESULTS: There were no statistically significant differences in the presence and localization of antibodies for collagen IV in the blood vessels and stroma between the two groups. However, the presence and localization of type IV collagen in the BM of the prenasal skin were significantly higher in DS specimens compared to the control group (P=0.023). When combining both groups altogether, a significant correlation was found between the increased prenasal thickness (PT) and the high presence and location of collagen type IV, irrespective of the karyotype results (Spearman's correlation; R=0.459; P=0.012). CONCLUSION: Using the immunohistochemistry technique, we were able to confirm the overexpression of collagen type IV in the BM of the prenasal area. This may explain the sonographic finding of increased PT seen mainly in DS fetuses.

Primary Ovarian Ectopic Pregnancy: Still a Medical Challenge.

OBJECTIVE: To investigate the clinical presentation of women with primary ovarian pregnancy diagnosed in recent years and to compare it to tubal pregnancy. STUDY DESIGN: Seven women treated for primary ovarian pregnancy from 2002-2013 were retrospectively identified and compared to 42 women with tubal pregnancies (involving either tubal rupture or tubal abortion) operated on during the same period. In the ovarian pregnancy group the pathology examination confirmed primary ovarian pregnancy according to the Spiegelberg criteria. RESULTS: Seven women underwent surgery for primary ovarian pregnancy during the study period. Five women presented with hemodynamic shock. A ruptured ovarian pregnancy was identified in all cases. Wedge resection was performed by laparotomy in 1 case and by laparoscopy in 6 cases. The mean estimated blood loss was significantly higher in those women with ovarian versus tubal pregnancy (1057.1 ± 472.1 mL vs. 250.2 ± 241.5 mL, respectively, p<0.001). Moreover, a statistically significant difference was found when we compared postoperative hospitalization days (2 ± 0.6 vs. 1.3 ± 0.7, respectively; p=0.01) in the ovarian pregnancy group as compared with the tubal pregnancy group. CONCLUSION: Primary ovarian ectopic pregnancy is still a major challenge for early diagnosis and treatment; it is associated with rupture and massive intraabdominal bleeding.

Analysis of Varicella-Zoster Virus in Temporal Arteries Biopsy Positive and Negative for Giant Cell Arteritis.

IMPORTANCE: Giant cell arteritis (GCA) is the most common systemic vasculitis in elderly individuals. Diagnosis is confirmed by temporal artery (TA) biopsy, although biopsy results are often negative. Despite the use of corticosteroids, disease may progress. Identification of causal agents will improve outcomes. Biopsy-positive GCA is associated with TA infection by varicella-zoster virus (VZV). OBJECTIVE: To analyze VZV infection in TAs of patients with clinically suspected GCA whose TAs were histopathologically negative and in normal TAs removed post mortem from age-matched individuals. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study for VZV antigen was performed from January 2013 to March 2015 using archived, deidentified, formalin-fixed, paraffin-embedded GCA-negative, GCA-positive, and normal TAs (50 sections/TA) collected during the past 30 years. Regions adjacent to those containing VZV were examined by hematoxylin-eosin staining. Immunohistochemistry identified inflammatory cells and cell types around nerve bundles containing VZV. A combination of 17 tertiary referral centers and private practices worldwide contributed archived TAs from individuals older than 50 years. MAIN OUTCOMES AND MEASURES: Presence and distribution of VZV antigen in TAs and histopathological changes in sections adjacent to those containing VZV were confirmed by 2 independent readers. RESULTS: Varicella-zoster virus antigen was found in 45 of 70 GCA-negative TAs (64%), compared with 11 of 49 normal TAs (22%) (relative risk [RR] = 2.86; 95% CI, 1.75-5.31; P < .001). Extension of our earlier study revealed VZV antigen in 68 of 93 GCA-positive TAs (73%), compared with 11 of 49 normal TAs (22%) (RR = 3.26; 95% CI, 2.03-5.98; P < .001). Compared with normal TAs, VZV antigen was more likely to be present in the adventitia of both GCA-negative TAs (RR = 2.43; 95% CI, 1.82-3.41; P < .001) and GCA-positive TAs (RR = 2.03; 95% CI, 1.52-2.86; P < .001). Varicella-zoster virus antigen was frequently found in perineurial cells expressing claudin-1 around nerve bundles. Of 45 GCA-negative participants whose TAs contained VZV antigen, 1 had histopathological features characteristic of GCA, and 16 (36%) showed adventitial inflammation adjacent to viral antigen; no inflammation was seen in normal TAs. CONCLUSIONS AND RELEVANCE: In patients with clinically suspected GCA, prevalence of VZV in their TAs is similar independent of whether biopsy results are negative or positive pathologically. Antiviral treatment may confer additional benefit to patients with biopsy-negative GCA treated with corticosteroids, although the optimal antiviral regimen remains to be determined.

Campylobacter coli infection causing second trimester intrauterine growth restriction (IUGR): a case report and review of the literature.

Campylobacter is a gram-negative, microaerophilic, curved rod and a normal resident of the gastrointestinal flora and may be the cause of disease in animals. Transmission to humans occurs by ingestion of contaminated food or by direct contact with infected animals. In the past few decades, an increasing number of reports have implicated the presence of this organism in human abortions as well. An infectious mechanism due to primary placental inflammatory damage followed by secondary damage to the fetus following placental insufficiency and ischemia was suggested. The most common species of Campylobacter are Campylobacter jejuni and Campylobacter coli, which are classically associated with enteritis in humans. We present a rare case of mid-gestation intrauterine growth restriction (IUGR) associated with maternal bacteremia caused by C. coli infection. Our literature review focuses on Campylobacter infections occurring in the second and third trimesters of pregnancy. In all cases, mild maternal symptoms consisting of fever and weakness were presented. However, associated adverse fetal outcome, including abortions, IUGR or preterm labor may occur more frequently than anticipated. Our report strengthens the importance of awareness to this finding and focuses the need to consume properly cooked meat during pregnancy.

Prevalence and distribution of VZV in temporal arteries of patients with giant cell arteritis.

OBJECTIVE: Varicella-zoster virus (VZV) infection may trigger the inflammatory cascade that characterizes giant cell arteritis (GCA). METHODS: Formalin-fixed, paraffin-embedded GCA-positive temporal artery (TA) biopsies (50 sections/TA) including adjacent skeletal muscle and normal TAs obtained postmortem from subjects >50 years of age were examined by immunohistochemistry for presence and distribution of VZV antigen and by ultrastructural examination for virions. Adjacent regions were examined by hematoxylin & eosin staining. VZV antigen-positive slides were analyzed by PCR for VZV DNA. RESULTS: VZV antigen was found in 61/82 (74%) GCA-positive TAs compared with 1/13 (8%) normal TAs (p < 0.0001, relative risk 9.67, 95% confidence interval 1.46, 63.69). Most GCA-positive TAs contained viral antigen in skip areas. VZV antigen was present mostly in adventitia, followed by media and intima. VZV antigen was found in 12/32 (38%) skeletal muscles adjacent to VZV antigen-positive TAs. Despite formalin fixation, VZV DNA was detected in 18/45 (40%) GCA-positive VZV antigen-positive TAs, in 6/10 (60%) VZV antigen-positive skeletal muscles, and in one VZV antigen-positive normal TA. Varicella-zoster virions were found in a GCA-positive TA. In sections adjacent to those containing VZV, GCA pathology was seen in 89% of GCA-positive TAs but in none of 18 adjacent sections from normal TAs. CONCLUSIONS: Most GCA-positive TAs contained VZV in skip areas that correlated with adjacent GCA pathology, supporting the hypothesis that VZV triggers GCA immunopathology. Antiviral treatment may confer additional benefit to patients with GCA treated with corticosteroids, although the optimal antiviral regimen remains to be determined.

Primary Ovarian Pregnancy: 43 Years Experience in a Single Institute and still a Medical Challenge.

BACKGROUND: Despite awareness regarding tubal pregnancy, ovarian pregnancy still remains a diagnostic challenge. The correct diagnosis is most frequently made intraoperatively and requires histopathologic confirmation. Therefore, additional diagnostic measurements are needed for earlier and more accurate detection of ovarian pregnancies which will allow more rapid and efficient treatment. OBJECTIVES: To assess the time trends, clinical manifestations, surgical management and post-procedure outcome of 46 primary ovarian pregnancies in a single institution during three time periods. METHODS: In this retrospective study we compared 20 patients with primary ovarian pregnancy during the years 1971- 1989 (first period), 19 patients in 1990-2001 (second period) and 7 patients in 2002-2013 (third period). In all cases the pathology examination confirmed primary ovarian pregnancy. RESULTS: The number of tubal ectopic pregnancies almost doubled, from 637 in the first period to 1279 in the third period (P < 0.001). However, there was a significant fall in the number of ovarian ectopic pregnancies, from 20 cases in the first period to 7 cases in the third (P = 0.009). A significant difference was noted when we compared the postoperative hospitalization time (4.06 ± 1.4 vs. 2.0 ± 0.6 days respectively, P = 0.001) in the second versus the third time period. CONCLUSIONS: Ovarian pregnancy continues to be a diagnostic challenge, associated with a high rate of circulatory collapse, hemoperitoneum and requirements for blood transfusions, all leading to longer hospitalization.

Clinical, surgical, and histopathologic outcomes following failed medical abortion.

OBJECTIVE: To address the consequences of surgical curettage following failed medical abortion. METHODS: A retrospective case-control study was performed in a tertiary gynecologic department. The case group comprised 104 women who underwent surgical curettage following failed medical abortion; the control group included 104 women who underwent early surgically induced abortion. Clinical characteristics and surgical findings were examined. The extent of inflammation was quantified following immunohistochemical staining for cell-surface markers characteristic of T lymphocytes, B lymphocytes, and macrophages. The extent of necrosis was evaluated morphologically. RESULTS: Abnormal findings during surgical curettage were significantly more prevalent among women in the case group than in the control group (10.6% versus 1.9%; P=0.019). The most frequent abnormality in the case group was the presence of intimately adherent products of conception, necessitating sharp curettage. The extent of inflammation (represented by increased numbers of T and B lymphocytes) was greater in the case group than in the control group (P=0.046 and P=0.001, respectively), as was the extent of necrosis (P<0.05). CONCLUSION: Curettage following failed medical abortion harbors particular difficulties, which may be attributed to an inflammatory response. The long-term consequences of curettage following failed medical abortion warrant further investigation.

Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy.

OBJECTIVES: The purpose of this study was to assess fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy. METHODS: We conducted a retrospective study in a large tertiary hospital in Israel. The study included 18 women with a diagnosis of cesarean scar pregnancy between 2000 and 2009. RESULTS: The incidence of cesarean scar pregnancy among our parturient patients was 1 per 3000 for the general obstetric population and 1 per 531 among those with at least 1 cesarean delivery. Sixteen were treated primarily with methotrexate. Two were treated primarily by surgery, and 2 more were treated by surgery after failed methotrexate treatment. After cesarean scar pregnancy treatment, 7 women conceived spontaneously, and 1 conceived by in vitro fertilization-intracytoplasmic sperm injection. The remaining 10 (55%) did not wish to conceive again. Two of the women who became pregnant (25%) had recurrent cesarean scar pregnancy. CONCLUSIONS: This study shows encouraging results for fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy. Nevertheless, the risk of recurrent cesarean scar pregnancy is not negligible.

Sex, age, and surgeon decision on nephron-sparing surgery are independent predictors of renal masses with benign histologic findings--a multicenter survey.

OBJECTIVES: To define the preoperative independent predictors indicating that renal mass has benign histologic features. METHODS: A total of 1664 patients with Stage T1-T2N0M0 with a unilateral renal mass underwent nephrectomy. The endpoint at multivariate analysis was benign versus malignant histologic features. RESULTS: The surgical approach (odds ratio [OR] 2.9, P = .0001), sex (OR 1.97, P = .0001), and age (OR 1.01, P = .007) were independent predictors for the malignant-benign distinction. Malignant tumors were more likely to occur in men (878 of 1009, 87%) versus women (515 of 651, 79%; P <.001). A weak relationship was found between an increasing tumor size and malignancy risk in men only. High-grade renal cell carcinoma was more prevalent in men (31% versus 21%, P = .001). The histologic tumor types were distributed differently between the 2 sexes: 8% papillary renal cell carcinoma in women versus 16% in men, 86% and 78% clear cell renal cell carcinoma, 33% and 57% oncocytoma, and 40% versus 12% angiomyolipoma, respectively. The physician's preoperative judgment regarding tumor amenability for nephron-sparing surgery resulted in patient selection: 10% benign tumors for radical nephrectomy versus 25% for partial nephrectomy (P = .001) and 31% versus 20% high-grade tumors, respectively (P = .0001). CONCLUSIONS: Renal tumors were consistently benign in 20% of women, regardless of size. In contrast, in men, the malignancy risk increased slightly with tumor size. The surgeons' preoperative decision regarding nephron-sparing surgery caused a selection bias in favor of benign lesions, regardless of sex. Our findings support the possibility of basing treatment decisions on the preoperative biopsy findings. Such changes could alter current practice and limit treatment of histologically proven benign lesions to surveillance or ablation only.

Twin tubal pregnancy: a rising complication?

OBJECTIVE: To present four cases of twin tubal pregnancies and discuss possible etiologies. Twin tubal pregnancies are a rare event, with incidence rates estimated as 1 out of 725-1,580 of tubal pregnancies. DESIGN: Case series. SETTING: Department of obstetrics and gynecology at a tertiary health care facility. PATIENT(S): All women with twin tubal pregnancy diagnosed and treated in the department during the years 2007-2009, according to electronic files and histologic reports. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Artificial reproductive technique preceding twin tubal pregnancies RESULT(S): We diagnosed four twin pregnancies of 163 tubal pregnancies, an incidence of 2.4%. Of the four cases, two conceived after gonadotropin stimulation and intrauterine insemination. The third conceived following in vitro fertilization and intracytoplasmic sperm injection. The fourth was a spontaneous conception diagnosed as monochorial monoamniotic twin tubal pregnancy. CONCLUSION(S): Twin tubal pregnancies may not be as rare as previously thought. Three of the four cases identified during a 2-year period followed artificial reproductive technique. We hope that this report will promote the study of the epidemiology of this event, improve diagnosis, and encourage the development of treatment modalities.

Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron sparing surgery.

OBJECTIVES: To define the rate of positive surgical margins (PSMs) and analyze the outcome of patients with PSMs. The outcome and proper management of patients with positive PSMs during nephron sparing surgery (NSS) are questionable. In this study we define the clinical outcomes of PSMs at NSS and suggest management. METHODS: Clinical records of 114 renal units who underwent open NSS for a renal mass between May 1995 and September 2005 were reviewed. RESULTS: PSMs were suspected on frozen section in 17 of 114 renal units (15%). Tumors with suspected PSMs at frozen section were smaller (2.9 +/- 1.6) in comparison to those with negative surgical margins (3.4 +/- 1.8 cm) (P = .001). Nine of 17 (53%) cases underwent total nephrectomy (5 immediately, 4 delayed). In 4 (24%), immediate re-excision of the renal crater was performed. A total of 4 (24%) that were followed up clinically were with no evidence of disease. Therefore, in 13 of 17 (77%) cases, the presence of tumor cells at the remaining side of the kidney could be evaluated histologically. In 2 cases from the immediate response group, tumor cells were found in the side opposite to the resection. There was no residual tumor in any case subjected to delayed nephrectomy. At median follow-up of 71 months, 15 of 17 patients are alive and with no evidence of disease. Two patients died because of unrelated causes. The overall 5-year survival rate is 98.2% and there is no cancer-specific mortality. CONCLUSIONS: The true PSM rate is in the range of 1.75%-5.26%. No disease progression or deaths attributable to renal cell carcinoma were associated with PSMs. Total nephrectomy should be avoided as a response to PSMs.

Pelvic splenosis--a gynaecological challenge.

Pelvic splenosis is a post-traumatic spleen autotransplantation, which can mimic various gynaecological diseases. A case of a 39-year-old woman, who underwent partial splenectomy because of a road accident in her childhood, currently presenting with abdominal pain and suspected corpus luteus torsion. Diagnostic laparoscopy was conducted which ruled out twisted ovary. This confirmed disseminated pelvic splenosis as a coincidental finding. Following this procedure, the abdominal pain ceased. The current report aims to raise the awareness of splenosis so that it may be appropriately recognized and differentiated from other pelvic findings.

Fetal abnormalities leading to third trimester abortion: nine-year experience from a single medical center.

OBJECTIVE: To assess fetal abnormalities and events leading to third-trimester abortion. METHODS: The study population included all parturient women with singleton pregnancy that underwent termination of pregnancy (TOP) in the third trimester in our institute because of fetal indications between 1998 and 2006. RESULTS: There were 777 cases of TOP due to fetal anomalies in our center during the study period, and 52 terminations were carried out in the third trimester. All cases of third-trimester abortions were due to severe malformations with high probability of perinatal death or severe handicap: 65.3% anomalies were structural, and 58.9% of them involved the central nervous system (CNS). Genetic indications included mostly genetic diseases, unlike aneupluidities in earlier terminations. Routine prenatal care raised suspicion of abnormalities in 22 (42.3%) cases, and diagnosis was established by additional tests. Abnormal findings were either missed in 4 (7.7%) cases or developed later in 11 (21.1%) cases. No routine prenatal screening was performed in the remaining 15 (28.8%) cases. CONCLUSIONS: Third-trimester abortion may be obviated by timely screening and scanning in some cases. The possibility of late TOP should be considered in malformations occurring late in pregnancy and in cases that require meticulous evaluation and follow-up from earlier stages of gestation.

Uterine-preserving emergency surgery for cesarean scar pregnancies: another medical solution to an iatrogenic problem.

OBJECTIVE: To supplement existing cases of cesarean scar pregnancy presenting as acute conditions. All of the study women had been treated by a conservative surgical approach. DESIGN: Retrospective study. SETTING: Department of obstetrics/gynecology of a tertiary referral center. PATIENT(S): We identified six pregnant women at 7-15 weeks' gestation who underwent emergency laparotomy and uterine-preserving surgery. Four of them were initially treated by uterine curettage because of misdiagnosed intrauterine pregnancies. The other two experienced failed methotrexate treatment. INTERVENTION(S): All patients underwent a similar surgical technique while actively bleeding. This included laparotomy and ligation of bilateral uterine arteries, followed by wedge resection of the entire pregnancy in scar. The uterus was sutured in two layers. MAIN OUTCOME MEASURE(S): All the reported women in our series had been cured and their uteruses have been preserved. RESULT(S): There was an inadvertent injury to the bladder in one case, which was immediately repaired, and blood transfusion was required in two other cases. The postoperative course was uneventful for all the patients. One of the patients has already spontaneously conceived and she had an ongoing normal pregnancy at the time of writing. CONCLUSION(S): This small case series emphasizes that uterine-preserving surgery is an optional management for cesarean scar pregnancies presenting as acute conditions, cases resistant to medical treatment, or for women at advanced gestation.

Clinical, sonographic, and epidemiologic features of second- and early third-trimester spontaneous antepartum uterine rupture: a cohort study.

OBJECTIVE: To present prenatal findings and maternal and neonatal outcomes following second- and early third-trimester spontaneous antepartum uterine rupture events in our institute. METHOD: Charts of patients with full-thickness second- or early third-trimester symptomatic uterine ruptures locally treated between 1984 and 2007 were evaluated. RESULTS: There were seven events involving six women, all requiring emergency laparotomy, and cesarean section (CS). During the study period in our institute, there were 120 636 singleton deliveries (> or =22 weeks' gestation), including 5 of our cases, while in 2 cases, the rupture occurred earlier (<22 weeks' gestation). The rupture occurred after > or = 1 previous CSs in five cases. Six events were associated with abnormal placentation: placenta previa (n = 3), placenta percreta (n = 1), or both (n = 2). Other associated events included short, interpregnancy (IP) interval (n = 3) and past uterine rupture (n = 2). Pregnant women at gestational age > or = 22 weeks, who had the combination of placenta previa, and previous CS (n = 3), had a higher chance for spontaneous symptomatic antepartum uterine rupture when compared to women with placenta previa without a previous CS (OR 29.3, 95% CI 1.5-569.3, p = 0.007). There were no maternal deaths. Three of the five viable neonates survived. CONCLUSIONS: Spontaneous symptomatic second- or early third-trimester uterine rupture in nonlaboring women is a very rare, obstetric emergency, which is hard to diagnose. Maternal and neonatal outcomes can be optimized by awareness of risk factors, recognition of clinical signs and symptoms, and availability of ultrasound to assist in establishing diagnosis, and enabling prompt surgical intervention.