Management of monoamniotic twin pregnancies: Where, when, how?

Management difficulties for monochorionic monoamniotic (MCMA) twin pregnancy reflect the absence of high-quality research into optimal types of monitoring, essential as MCMA twins have a high risk of intrauterine and neonatal death with perinatal mortality. D'Antonio et al's meta-analysis and the MonoMono study published in 2019, investigated the impact of monitoring location, out- or in-patient, of MCMA pregnancies and concluded that no specific management location is associated with improvement in prognosis. To evaluate the optimal timing for delivery of MCMA pregnancies, Van Mieghem and Chitrit carried out retrospective studies comparing gestational age of intrauterine death and risk of neonatal complication. The crossover point between the propective risk of intrauterine fetal death and neonatal complication was found at 32,33 weeks of gestation (WG), in accordance with American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynaecologists recommendations but inclusion of complicated pregnancies and analysis of fetuses individually may be regarded as a bias. The majority of studies of MCMA pregnancies focused on elective scheduled cesareans, with only rare retrospective studies reporting on vaginal delivery. Of these, two recent studies carried out by French teams suggest that vaginal deliveries may be as safe as cesarean births for MCMA twin pregnancies when specific criteria are met. In summary, concerning MCMA pregnancies, prognosis is not found to improve with inpatient management, optimal timing for delivery is at approximately 33 GW and vaginal delivery should not be excluded.

[Clinical characteristics and outcomes of monochorionic monoamniotic twin pregnancy].

Objective: To investigate the clinical characteristics and outcomes of monochorionic monoamniotic (MCMA) twin pregnancy. Methods: The clinical data of 60 MCMA twin pregnant women who were terminated in Peking University Third Hospital from January 2011 to December 2019 were collected, and the general clinical data, prenatal examination and pregnancy outcomes were analyzed retrospectively. Results: The age of 60 MCMA twin pregnant women was (31.0±4.1) years old, among which 44 cases were primiparas (73%, 44/60) and 16 cases were multiparas (27%, 16/60). Fifty-eight cases were diagnosed as MCMA twin pregnancy prenatally and were confirmed after delivery. Median ultrasonic diagnosis of gestational age was 12 weeks (range: 8-30 weeks). In the 60 MCMA twin pregnancies, 6 cases were conjoined twins, 5 cases were complicated with twin reversed arterial perfusion sequence (TRAPS), and 10 cases were diagnosed as other fetal malformation by prenatal ultrasound examination. Among the 60 MCMA twin pregnant women, 19 cases had spontaneous abortion or induced abortion due to fetal malformation, fetal death or other reasons within 28 weeks of pregnancy, 41 cases entered the perinatal period, a total of 70 newborns survived. The main cause of perinatal fetal or neonatal death was fetal dysplasia. Conclusions: There is a high incidence of fetal abnormality and perinatal mortality in MCMA twin pregnancy. Accurate early diagnosis, enhanced management and monitoring during pregnancy, and individualized treatment are the keys to improve MCMA twin pregnancy outcomes.

Misdiagnosis of a twin pregnancy with double-corner uterine rupture following salpingectomy and protrusion of the amniotic sac as an adnexal cyst: a case report.

BACKGROUND: Salpingectomy-associated uterine rupture during intrauterine pregnancy is rare in the clinic. We report a case of pregnancy with bilateral rupture of the uterine horns after bilateral salpingectomy. CASE PRESENTATION: A 30-year-old woman of Han ethnicity presented with right epigastric pain at 28 weeks and 6 days of gestation. Examination by colour Doppler ultrasound showed the following: "Twin live births with normal foetal umbilical artery blood flow indexes and a 183 mm × 112 mm anechoic zone in the right front of the uterus". Initially, we made an incorrect judgement wherein we considered the amniotic sac that was protruding into the abdominal cavity to be an adnexal cyst. Fortunately, the diagnosis of uterine rupture was confirmed before the protruded amniotic sac broke. The mother did not bleed much, and the twin foetuses survived in our case. CONCLUSION: A previous history of salpingectomy via laparoscopy could be a risk factor for uterine rupture in pregnant women. Attention should be paid to rare complications of pregnancy. To avoid adverse events, we should pay special attention to women with a history of laparoscopic salpingectomy who complain about abdominal discomfort and offer them a relevant ultrasound examination.

Continuous amnioinfusion for treatment of mid-trimester preterm premature rupture of membranes with oligoamnios.

AIM: Given the scarcity of relevant reports, this study aimed to elucidate whether pregnancy can be prolonged by maintaining the amniotic fluid volume with continuous transabdominal amnioinfusion (TA) for patients with mid-trimester preterm premature rupture of membranes (PPROM) and oligoamnios. METHODS: We retrospectively examined patients who were managed during hospitalization at our department after developing PPROM between week 22 day 0 and week 25 day 6 of gestation and subsequent oligoamnios (amniotic fluid index [AFI] <5 cm) within 7 days after PPROM onset. Cases between 2006 and 2011 comprised the conventional management group (n = 14); cases administered continuous TA between 2012 and 2017 comprised the continuous TA group (n = 14). The primary outcome was the number of days between PPROM and delivery. The secondary outcomes were the proportion of normal amniotic fluid volume (AFI ≥ 5 cm) maintained between PPROM and delivery and the perinatal prognosis for the mother and infant. RESULTS: The continuous TA group had significantly more days between PPROM and delivery and a significantly higher proportion of days that a normal amniotic fluid volume was maintained during that period, regardless of antimicrobial agents administered. Although no significant differences in the perinatal prognosis of disease were found between groups, there was a decreasing trend of composite perinatal mortality and morbidity, and the incidence rates were reduced by half. CONCLUSION: Continuous TA for PPROM with oligoamnios may allow significant prolongation of the gestation period while maintaining the amniotic fluid volume and may lead to improved perinatal prognosis.

Perfil de gestantes acometidas de parto prematuro em uma maternidade pública / Profile of the pregnant women affected by preterm birthing a public maternity hospital / Perfil de la mujer embarazada de trabajo afectada prematura en una maternidad pública

Objetivo: Caracterizar o perfil das gestantes acometidas de parto prematuro; descrever as complicações do parto prematuro; identificar o número de óbitos por parto prematuro. Método: Pesquisa retrospectiva; transversal com abordagem quantitativa; realizada em uma maternidade pública, a amostra que representou a população constituiu-se de 300 prontuários de gestantes com parto prematuro. Pesquisa aprovada pelo Comitê de Ética; sob CAAE nº 47429315.1.0000.5210. Resultados: Faixa etária predominante foi 14 a 19 anos 26,38%; escolaridade ensino médio (56,68%); situação conjugal casada (38,11%); ocupação do lar (48,21%); raça não registrada (99,67%); local de moradia zona rural (57,00%). Maior incidência de complicações dentro das variáveis; foram pré-eclâmpsia (28,66%); amniorrexe prematura (17,26%). Causa maior de óbito: Pré-eclâmpsia. Conclusão: Destaca-se que pré-eclâmpsia foi o agravo que causou o maior número de óbitos nas mulheres investigadas; esse dado evidencia as estatísticas alarmantes; confirmando que as doenças hipertensivas ocupam o primeiro lugar como causa de morte materna no Brasil

Objetivo: Caracterizar el perfil de parto prematuro afectaba a lãs mujeres embarazadas; describir lãs complicaciones Del nacimiento prematuro; identificar el número de muertes debidas al parto prematuro. Método: Estudio retrospectivo; cruzar com un enfoque cuantitativo; realizado em un hospital público, La muestra que representa la población constaba de 300 historias clínicas de mujeres embarazadas com trabajo de parto prematuro. De investigacióna probado por el Comité de Ética, La opinión Nº 1.175.971. Resultados: Rango de edad predominante fue de 14 a 19 años 26,38%; educación secundaria (56,68%); estado civil casada (38,11%); ocupación de la casa (48,21%); No raza registrado (99,67%); lugar de residencia, rural (57.00%). Mayor incidencia de complicaciones en las variables y preeclampsia (28,66%); ruptura prematura de membranas (17,26%). Principal causa de muerte: La pre-eclampsia. Conclusión: Es de destacar que La preeclampsia fue La lesión que causo el mayor número de muertes investigadas em lãs mujeres; estos datos pone de manifiesto las estadísticas alarmantes; lo que confirma que lãs enfermedades hipertensivas ocupan el primer lugar como causa de muerte materna en Brasil

Objective: Herein, our goal has been to characterize the pregnant women profile that experienced preterm birth. Moreover, describe the complications of preterm birth, and also to identify the number of deaths due to preterm birth. Methods: It is a retrospective cohort study with a quantitative approach, whichwas carried out in a public maternity hospital. The sample that represented the population consisted of 300 medical records of pregnant women with preterm birth. The research was approved by the Ethics Committee under the Legal Opinion No. 1,175,971. Results: The predominant age group was from 14 to 19 years old (26.38%); high school education (56.68%); married (38.11%); housekeeper (48.21%); unregistered race (99.67%); rural area as residence place (57.00%). The following were the higher incidence of complications within the variables: pre-eclampsia(28.66%) and premature amniorrexis (17.27%). The major cause of death was pre-eclampsia. Conclusion: It should be noted that pre-eclampsia caused the highest number of deaths in the women investigated and this fact shows the alarming statistics, confirming that hypertensive diseases occupy the first place as cause of maternal death in Brazil

Function and failure of the fetal membrane: Modelling the mechanics of the chorion and amnion.

The fetal membrane surrounds the fetus during pregnancy and is a thin tissue composed of two layers, the chorion and the amnion. While rupture of this membrane normally occurs at term, preterm rupture can result in increased risk of fetal mortality and morbidity, as well as danger of infection in the mother. Although structural changes have been observed in the membrane in such cases, the mechanical behaviour of the human fetal membrane in vivo remains poorly understood and is challenging to investigate experimentally. Therefore, the objective of this study was to develop simplified finite element models to investigate the mechanical behaviour and rupture of the fetal membrane, particularly its constituent layers, under various physiological conditions. It was found that modelling the chorion and amnion as a single layer predicts remarkably different behaviour compared with a more anatomically-accurate bilayer, significantly underestimating stress in the amnion and under-predicting the risk of membrane rupture. Additionally, reductions in chorion-amnion interface lubrication and chorion thickness (reported in cases of preterm rupture) both resulted in increased membrane stress. Interestingly, the inclusion of a weak zone in the fetal membrane that has been observed to develop overlying the cervix would likely cause it to fail at term, during labour. Finally, these findings support the theory that the amnion is the dominant structural component of the fetal membrane and is required to maintain its integrity. The results provide a novel insight into the mechanical effect of structural changes in the chorion and amnion, in cases of both normal and preterm rupture.

Aquaporins in ovine amnion: responses to altered amniotic fluid volumes and intramembranous absorption rates.

Aquaporins (AQPs) are transmembrane channel proteins that facilitate rapid water movement across cell membranes. In amniotic membrane, the AQP-facilitated transfer of water across amnion cells has been proposed as a mechanism for amniotic fluid volume (AFV) regulation. To investigate whether AQPs modulate AFV by altering intramembranous absorption (IMA) rate, we tested the hypothesis that AQP gene expression in the amnion is positively correlated with IMA rate during experimental conditions when IMA rate and AFV are modified over a wide range. The relative abundances of AQP1, AQP3, AQP8, AQP9, and AQP11 mRNA and protein were determined in the amnion of 16 late-gestation ovine fetuses subjected to 2 days of control conditions, urine drainage, urine replacement, or intraamniotic fluid infusion. AQP mRNA levels were determined by RT-qPCR and proteins by western immunoblot. Under control conditions, mRNA levels among the five AQPs differed more than 20-fold. During experimental treatments, mean IMA rate in the experimental groups ranged from 100 ± 120 mL/day to 1370 ± 270 mL/day. The mRNA levels of the five AQPs did not change from control and were not correlated with IMA rates. The protein levels of AQP1 were positively correlated with IMA rates (r(2) = 38%, P = 0.01) while the remaining four AQPs were not. These findings demonstrate that five AQPs are differentially expressed in ovine amnion. Our study supports the hypothesis that AQP1 may play a positive role in regulating the rate of fluid transfer across the amnion, thereby participating in the dynamic regulation of AFV.

Amniotic membrane sweeping.

Amniotic membrane sweeping or stripping is a safe and effective method of labor induction supported by national obstetrical organizations. While its use dates back to antiquity by both midwives and physicians there are still areas that need further research to define its role in induction of labor. A review of the literature reveals that amniotic membrane sweeping is a safe, effective, and inexpensive method of labor induction. It can be done in the outpatient setting with minimal risks so long as it is avoided in patients with contraindications. Amniotic membrane sweeping can be performed in Group B Streptococcus-positive women with studies showing no increase in untoward outcomes. However, there is no data in women infected with HIV or hepatitis.

Monochorionic twin placentas: injection technique and analysis / Placentas monocoriónicas: técnicas de inyección y análisis

Careful placenta examination and injection studies are crucial to understand the differences between the various complications in monochorionic (MC) pregnancies. In this review, we will first describe an accurate and simple method of placental injection and then discuss the placental characteristics of normal MC, twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS), selective intrauterine growth restriction (sIUGR), monoamniotic (MA) and other special cases (AU)

El examen cuidadoso de la placenta y los estudios de inyección son cruciales para comprender las diferencias existentes entre las diversas complicaciones de los embarazos MC. En esta revisión, vamos a describir primero un método preciso y simple de inyección placentaria y, posteriormente, abordaremos las características de una placenta normal en MC, el síndrome de transfusión fetal-fetal (STFF), la secuencia anemia-policitemia (SAP), la restricción del crecimiento intrauterino selectivo (CIRs), la placenta monoamniótica (MA) y otros casos especiales (AU)

[Amniotic embolism--damocles sword or lifebelt?].

The author deals with classical and contemporary concepts of amniotic embolism in terms of medical and legal aspects associated with this potentially lethal condition.

Intra-amniotic infection/inflammation as a risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor.

The aim of this study was to determine whether intra-amniotic infection/inflammation (IAI) was associated with subsequent ruptured membranes in women with preterm labor and intact membranes who had a clinically indicated amniocentesis. This retrospective cohort study included 237 consecutive women with preterm labor (20-34.6 weeks) who underwent amniocentesis. The clinical and laboratory parameters evaluated included demographic variables, gestational age, C-reactive protein (CRP) and amniotic fluid (AF) white blood cell, interleukin-6 (IL-6) and culture results. IAI was defined as a positive AF culture and/or an elevated AF IL-6 level (>2.6 ng/mL). The primary outcome was ruptured membranes in the absence of active labor occurring within 48 hours of amniocentesis. Preterm premature rupture of membranes subsequently developed in 10 (4.2%) women within 48 hr of amniocentesis. Multivariate analysis demonstrated that only IAI was independently associated with the ruptured membranes occurring within 48 hr of amniocentesis. In the predictive model based on variables assessed before amniocentesis, only CRP level was retained. IAI is an independent risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor. Prior to amniocentesis, measurement of serum CRP level can provide a risk assessment for the subsequent development of ruptured membranes after the procedure.

Senescence in amniocytes and placentas from trisomy 21 pregnancies.

OBJECTIVE: Senescence has been described as a stable cell proliferation arrest resulting from the progression of primary human fibroblasts through a finite number of population doublings in vitro. Accelerated telomere shortening was observed in pregnancies complicated by intrauterine growth restriction, in placentas of diabetic mothers and trisomy 21 amniocytes. We hypothesized that under conditions of stress, telomeres in placentas will be shorter and there will be more cells with the senescence phenotype. METHODS: The two study groups included placental biopsies from 7 cases of trisomy 21 and amniocytes from 10 cases of trisomy 21. The control groups consisted of placental biopsies from 6 cases and amniocytes from 10 pregnancies with a normal karyotype. The samples were analyzed for the presence of senescent cells based on the number of fragments in each cell. RESULTS: A significantly higher percentage of cells in the senescent state, based on a higher percentage of cells with more fragmentations, were found in the amniocytes (20.8%) and in trophoblasts (94.3%) from placentas with trisomy 21 compared to the control groups. CONCLUSION: Among other genetic instability parameters, trisomy 21 amniocytes and trophoblasts express a higher prevalence of senescent cells than were previously reported.

Intra-Amniotic Infection/Inflammation as a Risk Factor for Subsequent Ruptured Membranes after Clinically Indicated Amniocentesis in Preterm Labor

The aim of this study was to determine whether intra-amniotic infection/inflammation (IAI) was associated with subsequent ruptured membranes in women with preterm labor and intact membranes who had a clinically indicated amniocentesis. This retrospective cohort study included 237 consecutive women with preterm labor (20-34.6 weeks) who underwent amniocentesis. The clinical and laboratory parameters evaluated included demographic variables, gestational age, C-reactive protein (CRP) and amniotic fluid (AF) white blood cell, interleukin-6 (IL-6) and culture results. IAI was defined as a positive AF culture and/or an elevated AF IL-6 level (>2.6 ng/mL). The primary outcome was ruptured membranes in the absence of active labor occurring within 48 hours of amniocentesis. Preterm premature rupture of membranes subsequently developed in 10 (4.2%) women within 48 hr of amniocentesis. Multivariate analysis demonstrated that only IAI was independently associated with the ruptured membranes occurring within 48 hr of amniocentesis. In the predictive model based on variables assessed before amniocentesis, only CRP level was retained. IAI is an independent risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor. Prior to amniocentesis, measurement of serum CRP level can provide a risk assessment for the subsequent development of ruptured membranes after the procedure.

Membrana amniótica como alternativa de tratamiento en superficie ocular / Amniotic membrane as a therapeutic option for the ocular surface

Se realizó una revisión bibliográfica con el objetivo de conocer la utilidad de la membrana amniótica como alternativa de tratamiento en la superficie ocular. Son abordados tópicos como las diferentes formas de obtención, preparación y conservación de la misma, sus mecanismos de acción y aplicaciones. Se consultó una bibliografía que abarca un periodo de varios años para conocer los resultados publicados sobre el trasplante de membrana amniótica humana en la superficie ocular. ..

A literature review was made to learn about the usefulness of the amniotic membrane as a therapeutic option for the ocular surface. The different ways for obtaining, preparing, and conserving this membrane, its mechanism of action and its applications were also addressed. Literature covering several years was reviewed in order to be acquainted with the published results of the human amniotic membrane transplantation on the ocular surface...

Membrana amniótica como alternativa de tratamiento en superficie ocular / Amniotic membrane as a therapeutic option for the ocular surface

Se realizó una revisión bibliográfica con el objetivo de conocer la utilidad de la membrana amniótica como alternativa de tratamiento en la superficie ocular. Son abordados tópicos como las diferentes formas de obtención, preparación y conservación de la misma, sus mecanismos de acción y aplicaciones. Se consultó una bibliografía que abarca un periodo de varios años para conocer los resultados publicados sobre el trasplante de membrana amniótica humana en la superficie ocular. ..

A literature review was made to learn about the usefulness of the amniotic membrane as a therapeutic option for the ocular surface. The different ways for obtaining, preparing, and conserving this membrane, its mechanism of action and its applications were also addressed. Literature covering several years was reviewed in order to be acquainted with the published results of the human amniotic membrane transplantation on the ocular surface...

Fetal thoracoamniotic shunting for large macrocystic congenital cystic adenomatoid malformations of the lung.

OBJECTIVE: To evaluate fetal thoracoamniotic shunting for isolated large macrocystic congenital cystic adenomatoid malformations (CCAM) of the lung. METHODS: This was a retrospective study of 11 fetuses with macrocystic CCAM who underwent thoracoamniotic shunting. This procedure was offered if fetal hydrops or signs of evolving hydrops (such as ascites or polyhydramnios) were present, or when there were very large lesions or lesions rapidly increasing in size. If there were multiple large cysts within the lesion, a single shunt was used, aiming to traverse several cysts. RESULTS: Shunts were inserted at a mean gestational age of 24.6 (range, 17-32) weeks. Marked mediastinal shift was present in all cases. Six fetuses were hydropic and, of the remaining five, one had severe polyhydramnios, three had lesions that were rapidly increasing in size and one had a very large lesion at initial presentation. In total, four cases had polyhydramnios. Shunting one cyst always decompressed the entire lesion and hydrops and/or polyhydramnios resolved in all surviving fetuses. One hydropic fetus that underwent the procedure at 17 weeks died 1 day later. The shunt dislodged in one case and the lesion did not re-expand. No mother went into labor or had ruptured membranes before 35.6 weeks. Mean gestational age at delivery was 38.2 weeks (n = 10). All pregnancies were delivered vaginally, with no maternal complications. All newborns had uneventful lobectomies, and pathology confirmed CCAM in all cases. CONCLUSION: Fetal thoracoamniotic shunting for large macrocystic CCAM is associated with favorable outcome in most cases, and should be considered in severe cases even before hydrops develops.

The effects of thrombin and cytokines upon the biomechanics and remodeling of isolated amnion membrane, in vitro.

Abruption-induced thrombin generation and inflammation/infection induced cytokine production have both been associated with fetal membrane (FM) weakening and preterm premature rupture of the fetal membranes (PPROM). Using our in vitro model system we have demonstrated that thrombin, and separately the cytokines, tumor necrosis factor-alpha (TNFα) and interleukin-1-beta (IL-1ß), remodel and weaken full thickness FM. Additionally, we have reported that the anti-oxidant and NFκB inhibitor, alpha-lipoic acid (LA), blocks these thrombin and cytokine induced effects. The purpose of these studies was to determine whether thrombin and cytokines directly weaken the amnion membrane (AM), the major load-bearing component of FM. Isolated AM or full thickness FM fragments from unlabored Cesarean deliveries were incubated with thrombin, TNFα, or IL-1ß, for 48 h. Rupture strength (breaking force) of each fragment was thereafter determined using our published methodology. Biochemical evidence of remodeling and apoptosis; immunoreactive Matrix Metalloproteinase 9 (MMP9), Tissue Inhibitor of Matrix Metalloproteinase 3 (TIMP3) and cleaved poly (ADP-ribose) polymerase (C-PARP) levels in tissue extracts, were determined by western blot and densitometry. Thrombin induced a dose-dependent weakening of isolated AM (P < 0.001) coupled with dose dependent increases in PARP cleavage, and reciprocal increases and decreases, respectively, in MMP9 and TIMP3 protein (all P < 0.01). Thrombin receptor activating peptide-6 (TRAP) also weakened isolated AM. Neither TNFα nor IL-1ß weakened isolated AM. However, both cytokines weakened AM when it was incubated together with the choriodecidua as part of full thickness FM (P < 0.001). Cytokine-conditioned choriodecidua medium also weakened isolated AM (P < 0.001). Under conditions in which cytokines weakened the AM, the changes in MMP9, TIMP3 and PARP cleavage were consistent with those seen after thrombin incubation. LA blocked the FM weakening and remodeling effects. In summary, thrombin weakens AM directly whereas cytokines weaken AM indirectly by causing the release of soluble intermediates from the choriodecidua.

Monochorionic monoamniotic twin pregnancies with two yolk sacs may not be a rare finding: a report of two cases.

The exact determination of amnionicity is a major issue for the clinical management of monochorionic twin pregnancies, due to the high risk of perinatal mortality and morbidity in monochorionic monoamniotic (MCMA) twins. Counting the number of yolk sacs is believed to be a good indicator of amnionicity in the early first trimester, and it has previously been suggested that the number of yolk sacs is equal to amnionicity in both MCMA and monochorionic diamniotic twin pregnancies. However, the accuracy of the relationship between number of yolk sacs and amnionicity has recently been called into question. To the best of our knowledge, no previous reports have shown two yolk sacs in MCMA twin pregnancies. We report two cases of MCMA twins with two yolk sacs on first-trimester ultrasonography, and confirmed monoamnionicity in the second trimester showing umbilical cord entanglement. Postnatal examination showed an MCMA placenta in both cases, and entangled umbilical cords confirmed monoamnionicity. The possibility of monoamnionicity must still be suspected when two yolk sacs are detected early in the first trimester on ultrasound examination in monochorionic twin pregnancies.

Tratamiento con membrana amniótica en queratolisis secundaria a queratoconjuntivitis gonocócica del adulto / Treatament with amniotic membrane in keratolysis secondary to adult gonococcal keratoconjunctivitis

Caso clínico: Varón de 46 años diagnosticado inicialmentede conjuntivitis adenovírica atípica conqueratolisis marginal avanzada y riesgo de perforaciónocular. El diagnóstico final fue queratoconjuntivitisgonocócica. El paciente fue tratado eficazmentecon recubrimiento de membrana amniótica,ceftriaxona tópica y sistémica (50 mg/ml y1 gr/12 h intravenosa).Discusión: La gonorrea debe ser sospechada encasos de conjuntivitis de evolución tórpida(AU)

Case report: We present a 46-year-old man diagnosedinitially with atypical adenoviral conjunctivitisand advanced marginal queratolysis with risk ofperforation. The final diagnosis was gonococcalkeratoconjunctivitis. The patient was successfullytreated with amniotic membrane transplant, topicand systemic ceftriaxone (50 mg/ml and 1 grame/12hours intravenous).Discussion: Gonorrhea must be suspected in casesof torpid evolution conjunctivitis(AU)