Unruptured 32-week rudimentary horn pregnancy presenting as right upper quadrant pain.

BACKGROUND: An unruptured third trimester rudimentary horn pregnancy is rare, life threatening, and can go undetected until the onset of symptoms. Given the high risk of uterine rupture, conservative management after viability is controversial. CASE: A 21 year-old with a 32-week rudimentary horn pregnancy, diagnosed via exploratory laparotomy five days earlier, presented with acute right upper quadrant pain. The patient underwent cesarean delivery. The rudimentary horn was noted to be intact, but so thin it was transparent. CONCLUSION: Advanced ectopic pregnancy or rudimentary horn pregnancy should be considered in cases of unusual or undiagnosed abdominal pain in pregnancy. When surgical exploration is performed, an incision allowing optimal visualization and exposure is recommended.

"There they go again"--hCG and weight loss.

Dr. Albrink's review of information available in 1969 did not allow her to determine a physiologic basis for the use of hCG or any proof of immediate or long term benefit. Subsequent discoveries and clinical studies only support her impressions. Despite these facts, this form of therapy has achieved a resurgence in popularity. The difference today is that patients no longer have to rely on health care providers to prescribe their medications since internet sites allow them to obtain medications "on line". This has potential adverse ramifications when we consider that the initial use of gonadotropins derived from the human pituitary was discontinued due to the iatrogenic transmission of Creutzfeld-Jakob disease. It is thought that the disease is transmitted by an abnormal protein called prion protein. Subclinical forms of the disease exist and the prions could potentially be transmitted in urine. No cases or transmission via urine have been reported and reputable sources of hCG would appear to be safe, but products from countries with greater risk have the potential for contamination. The increased demand for hCG from reputable sources has led to shortages and increased expense for the legitimate uses of hCG in treatment of endocrine disorders and infertility. Obesity and the adverse impact on health has become a priority in public health policies for the state of West Virginia and for our nation as a whole. The benefit of longevity in the practice of medicine is that one is given the opportunity to observe attempts to "reinvent the wheel" where medical practices that have been previously disproven are reintroduced. Fineberg and Hiatt state this more eloquently when they said: "What is unacceptable is to persist in demonstrably ineffective practices either because we fail to collect systematic information about the effects of our actions or because we establish and respond to inappropriate incentives." Systematic information has been obtained and has shown lack of evidence for the benefit of this therapy. The alternative explanation for the persistence and promotion of this treatment is unacceptable.

Successful pregnancy following conservative surgical therapy of an invasive molar gestation.

BACKGROUND: An invasive mole is a form of persistent trophoblastic disease. The traditional surgical treatment is hysterectomy. CASE: A young nullipara presented with a positive pregnancy test 6 months following a suction curettage for an incomplete abortion. Radiologic imaging was suspicious for intramural ectopic gestation. She was treated with methotrexate but became thrombocytopenic with failure to resolve the abnormal gestation. Surgical excision of the mass was performed. Pathologic evaluation revealed the diagnosis of invasive molar pregnancy. The beta-hCG levels remained negative for greater than a year. The patient subsequently conceived and underwent a cesarean delivery of a viable infant at 36 weeks gestation. CONCLUSION: Conservative surgical excision can successfully treat invasive molar gestation. This should be considered for patients who desire future fertility and have contraindications to medical therapy.

Hyperandrogenemia associated with insulin resistance mimicking an androgen producing tumor.

The finding of a serum testosterone level greater than 200 ng/dl in a woman with virilization raises concerns about an androgen producing tumor. This case report demonstrates that chronic annovulation in association with insulin resistance can cause significant elevations in the level of serum testosterone, and describes the therapeutic benefit of insulin sensitizing agents in reversing hyperandrogenemia.