Case Reports in Obstetrics and Gynecology The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Tuboovarian Abscess as Primary Presentation for Imperforate Hymen Wed, 16 Apr 2014 09:07:45 +0000 Objective. Imperforate hymen represents the extreme in the spectrum of hymenal embryological variations. The archetypal presentation in the adolescent patient is that of cyclical abdominopelvic pain in the presence of amenorrhoea. We reported a rare event of imperforate hymen presenting as a cause of tuboovarian abscess (TOA). Case Study. A 14-year-old girl presented to the emergency department complaining of severe left iliac fossa pain. It was her first episode of heavy bleeding per vagina, and she had a history of cyclical pelvic pain. She was clinically unwell, and an external genital examination demonstrated a partially perforated hymen. A transabdominal ultrasound showed grossly dilated serpiginous fallopian tubes. The upper part of the vagina was filled with homogeneous echogenic substance. Magnetic resonance imaging (MRI) demonstrated complex right adnexa mass with bilateral pyo-haemato-salpinges, haematometra, and haematocolpos. In theatre, the imperforate hymen was opened via cruciate incision and blood was drained from the vagina. At laparoscopy, dense purulent material was evacuated prior to an incision and drainage of the persistent right TOA. Conclusion. Ideally identification of imperforate hymen should occur during neonatal examination to prevent symptomatic presentation. Our case highlights the risks of late recognition resulting in the development of sepsis and TOA. Jeh Wen Ho, D. Angstetra, R. Loong, and T. Fleming Copyright © 2014 Jeh Wen Ho et al. All rights reserved. Necrotizing Fasciitis and Toxic Shock Syndrome from Clostridium septicum following a Term Cesarean Delivery Sun, 13 Apr 2014 13:24:50 +0000 Necrotizing fasciitis and toxic shock syndrome are life-threatening conditions that can be seen after any surgical procedure. With only 4 previous published case reports in the obstetrics and gynecology literature of these two conditions occurring secondary to Clostridium septicum, we describe a case of necrotizing fasciitis and toxic shock syndrome occurring after a term cesarean delivery caused by this microorganism, requiring aggressive medical and surgical intervention. B. H. Rimawi, W. Graybill, J. Y. Pierce, M. Kohler, E. A. Eriksson, M. T. Shary, B. Crookes, and D. E. Soper Copyright © 2014 B. H. Rimawi et al. All rights reserved. Ependymoma and Carcinoid Tumor Associated with Ovarian Mature Cystic Teratoma in a Patient with Multiple Endocrine Neoplasia I Thu, 10 Apr 2014 09:12:55 +0000 Ovarian teratomas rarely undergo new neoplastic transformation and account for a small percentage of malignant ovarian germ cell neoplasms. Here we report a case of a 51-year-old woman with multiple endocrine neoplasia type I (MEN I) who was found to have an ependymoma and neuroendocrine tumor (trabecular carcinoid) associated with mature cystic teratoma of her left ovary. The ependymoma component displayed cells with round nuclei and occasional small nucleoli which were focally arranged in perivascular pseudorosettes and true rosettes. Rare mitoses were identified. No necrosis was present. Immunohistochemical staining was positive for S-100 and GFAP. The Ki67 proliferation index was very low (2-3%). In contrast, the endocrine tumor component was composed of small uniform cells with eosinophilic cytoplasm, round nuclei, and speckled chromatin. Immunohistochemical staining was positive for synaptophysin and focally positive for chromogranin. This rare case illustrates that MEN I may have an influence on the pathogenesis of ovarian teratomas as they undergo malignant transformation. Reed Spaulding, Houda Alatassi, Daniel Stewart Metzinger, and Mana Moghadamfalahi Copyright © 2014 Reed Spaulding et al. All rights reserved. Acute and Chronic Fetal Anemia as a Result of Fetomaternal Hemorrhage Mon, 07 Apr 2014 15:37:57 +0000 Introduction. Fetomaternal hemorrhage represents a transfer of fetal blood to the maternal circulation. Although many etiologies have been described, most causes of fetomaternal hemorrhage remain unidentified. The differentiation between acute and chronic fetomaternal hemorrhage may be accomplished antenatally and may influence perinatal management. Case. A 36-year-old gravida 6 para 3 presented at 37 and 5/7 completed gestational weeks with ultrasound findings suggestive of chronic fetal anemia such as right ventricular enlargement, diminished cerebral vascular resistance, and elevated middle cerebral artery end-diastolic velocity. On the other hand, signs of acute fetal decompensation such as deterioration of the fetal heart tracing, diminished biophysical score, decreased cord pH, and increased cord base deficit were noted. Following delivery, the neonate’s initial hemoglobin was 4.0 g/dL and the maternal KB ratio was 0.015 indicative of a significant fetomaternal hemorrhage. Discussion. One should consider FMH as part of the differential diagnosis for fetal or immediate neonatal anemia. We describe a unique case of FMH that demonstrated both acute and chronic clinical features. It is our hope that this case will assist practitioners in differentiating acute FMH that may require emergent delivery from chronic FMH which may be able to be expectantly managed. Paul Singh and Tara Swanson Copyright © 2014 Paul Singh and Tara Swanson. All rights reserved. Large Mucocele of the Appendix at Laparoscopy Presenting as an Adnexal Mass in a Postmenopausal Woman: A Case Report Sun, 06 Apr 2014 07:55:15 +0000 A 79-year-old female was referred to our Gynecologic Department presenting with a pelvic magnetic resonance imaging (MRI), showing an adnexal mass, later confirmed at the pelvic examination. The patient’s routine laboratory tests were normal. A sonographic examination was performed with inconclusive results. Although the ultrasonography excluded the presence of vascularization and malignant degeneration, the adnexal localization appeared to be dubious. The laparoscopy and the subsequent histologic examination revealed the presence of a mucocele of the appendix. The following case report focuses the attention on a misdiagnosis of appendiceal mucocele. The misdiagnosis caused no negative impact on the treatment that in this case was adequate and successful. Elvira Paladino, Maria Bellantone, Francesca Conway, Francesco Sesti, Emilio Piccione, and Adalgisa Pietropolli Copyright © 2014 Elvira Paladino et al. All rights reserved. HELLP Syndrome Complicated by Subcapsular Hematoma of Liver: A Case Report and Review of the Literature Wed, 02 Apr 2014 13:57:14 +0000 Subcapsular liver hematoma (SLH) is a rare complication of severe preeclampsia and HELLP syndrome. These patients must be followed up in intensive care unit for advanced medical support with infused fluid, replacement of blood products, and treatment of underlying disorders. There are a lot of therapeutic options varying from conservative management to surgical treatment including hepatic resection, hepatic artery ligation, and liver transplantation. In this report we aimed to present a 26-year-old woman with SLH secondary to HELLP syndrome. Atilla Karateke, Dilek Silfeler, Faruk Karateke, Raziye Kurt, Ayse Guler, and Ismail Kartal Copyright © 2014 Atilla Karateke et al. All rights reserved. Robotic-Assisted Dissection of Bulky Lymph Nodes in Cervical Cancer Tue, 01 Apr 2014 09:13:23 +0000 The resection of bulky lymph node metastases, which may provide a therapeutic benefit, has been proposed in several studies based on laparotomy and laparoscopy. There is no published study in the literature examining the resection of bulky lymph node metastases using a robotic technique. In this report, we presented a patient with cervical cancer who underwent robotic-assisted dissection of bulky lymph nodes. The robotic-assisted operation time was 255 minutes, and the mean console time was 215 minutes. The estimated blood loss was 70 mL. The number of lymph nodes retrieved was 28, and the number of the dissected paraaortic lymph nodes was 13. The number of the lymph node metastases was eight. The bulky lymph nodes which are difficult to be eradicated with standard radiation therapy can be resected with robotic-assisted surgery and successful resection of the lymph nodes can improve the treatment strategy. This minimal invasive technique is safe and feasible for bulky lymph node dissection. Ahmet Göçmen, Fatih Şanlıkan, and Muhittin Eftal Avcı Copyright © 2014 Ahmet Göçmen et al. All rights reserved. Reactive Nodular Fibrous Pseudotumor: Case Report and Review of the Literature Sun, 30 Mar 2014 13:10:29 +0000 We will describe a case of a patient diagnosed with a rare identity of a benign lesion, “reactive nodular fibrous pseudotumor” (RNFP). It is a tumor which preoperatively can present as a malignant tumor and is only reported in 19 cases. According to the very limited amount of information on this tumor in the literature it is mostly seen after trauma or intraperitoneal inflammation. Our case is the second one of RNFP associated with endometriosis, which is a frequently seen intraperitoneal inflammation process in women. Knowledge that these large pseudotumoral lesions can occur is important to direct the management of these patients. Rawand Salihi, Philippe Moerman, Dirk Timmerman, Dominique Van Schoubroeck, Katya Op de beeck, and Ignace Vergote Copyright © 2014 Rawand Salihi et al. All rights reserved. Shortened Cervix in the Subsequent Pregnancy after Embolization for Postpartum Cervical Hemorrhage Sun, 30 Mar 2014 09:42:52 +0000 Introduction. Rupture of a branch of uterine artery during delivery often leads to a massive postpartum hemorrhage that can be successfully treated using uterine artery embolization. Case Report. A 33-year-old woman had a cesarean section at term followed by a secondary postpartum hemorrhage due to a ruptured cervicovaginal branch terminating in a large, partially thrombosed hematoma of the cervix. She was given selective uterine artery embolization, and she was discharged to home in stable condition on the third day after embolization. In the forthcoming pregnancy a shortened cervix was a risk of threatened premature delivery from 26 weeks of gestation onwards. Conclusion. Superselective unilateral embolization of a thrombosed hematoma in the cervix might prevent extensive iatrogenic trauma of the cervix, which allows preservation of reproductive function. Zoltan Kozinszky, Sverre Sand, Nils-Einar Kløw, and Kirsten Hald Copyright © 2014 Zoltan Kozinszky et al. All rights reserved. An Unusual Cervical Tumor as Presentation of a Non-Hodgkin Lymphoma Mon, 24 Mar 2014 12:18:44 +0000 Rare cervical cancers are responsible for a minority of cases encountered by a clinician. However, behavioral patterns, management, and prognosis of certain rare cervical cancers differ from either squamous carcinomas or adenocarcinomas. Here we present a case of a locally advanced cervical tumor as a presentation of an extranodal cervical non-Hodgkin lymphoma (NHL), with a review of the current literature. Tom De Greve, Lieve Vanwalleghem, Achiel Van Hoof, Kenneth Coenegrachts, and Philippe Van Trappen Copyright © 2014 Tom De Greve et al. All rights reserved. A Second Trimester Caesarean Scar Pregnancy Sun, 23 Mar 2014 13:23:06 +0000 Caesarean scar pregnancy, where conceptus is implanted on previous scar, is a rare entity. We present one such case of scar pregnancy presenting to us in the second trimester and was managed with methotrexate and uterine artery embolization, followed by hysterotomy. Uterus could be conserved and hysterectomy could be avoided. Pooja Sikka, Vanita Suri, Seema Chopra, and Neelam Aggarwal Copyright © 2014 Pooja Sikka et al. All rights reserved. Prenatal Diagnosis of Cantrell’s Pentalogy Associated with Agenesis of Left Limb in a Twin Pregnancy Sun, 23 Mar 2014 07:29:01 +0000 Pentalogy of Cantrell is a rare malformation described in the literature. We report a case of pentalogy of Cantrell associated with left limb deficiency in a twin pregnancy. The fetus with multiple anomalies revealed kyphosis, ectopia cordis, and a large defect with protruding liver and bowel loops at 12 weeks and 3 days of gestational age on ultrasound scan. The other fetus was ultrasonographically normal. We diagnosed a case of pentalogy of Cantrell in a twin pregnancy after exclusion of limb body wall complex, body stalk anomaly, and amniotic band syndrome and after delivery of the fetuses. Macroscopic examinations were ectopia cordis, extrusion of the abdominal organs without membranes surrounding, and agenesis of the left limb. Yigit Cakiroglu, Emek Doger, Sule Yildirim Kopuk, Kadir Babaoglu, Eray Caliskan, and Gulseren Yucesoy Copyright © 2014 Yigit Cakiroglu et al. All rights reserved. A Rare Localization of Ectopic Pregnancy: Intramyometrial Pregnancy in Twin Pregnancy following IVF Tue, 18 Mar 2014 08:27:31 +0000 Intramyometrial pregnancy is a rare form of ectopic pregnancy. It makes a diagnostic and therapeutic challenge. If misdiagnosed the intramyometrial pregnancy can cause a uterine rupture and become life-threatening condition. We report a case of intramyometrial pregnancy in twin pregnancy following IVF with spontaneous abortion of the first twin At 9 weeks of gestation. The 10 weeks scan showed a normal fetus which was described to be highly localized in the uterus but the diagnosis of intramyometrial pregnancy was not suspected. The patient was admitted at 14 weeks of gestation with pelvic pain, hemorrhage, and shock. She was operated and the diagnosis of ruptured intramyometrial pregnancy was done and managed conservatively. This case illustrates the diagnostic difficulties of intramyometrial pregnancy. We discuss pathophysiology, diagnosis, and treatment of this exceptional form of ectopic pregnancy. Lahcen Boukhanni, Yassir Ait Benkaddour, Ahlam Bassir, Abdrahim Aboulfalah, Hamid Asmouki, and Abderraouf Soummani Copyright © 2014 Lahcen Boukhanni et al. All rights reserved. LMN Facial Palsy in Pregnancy: An Opportunity to Predict Preeclampsia—Report and Review Mon, 17 Mar 2014 16:32:38 +0000 Facial paralysis is the most frequent unilateral cranial nerve pathology affecting pregnant population 2 to 4 times more often than the nonpregnant population. There exists an association with preeclampsia but this has largely been overlooked. Clinicians often dismiss it for idiopathic palsy as seen in the present case. A 30-year-old woman, Gravida 4, Para 3, presented at 26 weeks pregnancy with complaints of facial weakness, blurring of vision, altered taste sensation, increased noise sensitivity for 1 month, headache since 18 days, and vomiting since 2­3 days. Her pulse was 90/min, BP was 170/120, and RR was 18/min. Uterus was 18 weeks size and proteinuria++ was present. Ultrasonography revealed a 26 weeks fetus, severe bradycardia, and absent liquor. HELLP syndrome was diagnosed after investigations. Six units of fresh frozen plasma were transfused. An informed decision for termination of pregnancy was made. She delivered a 450 gram stillborn. The third stage was complicated with postpartum hemorrhage but it was managed successfully. Women with Bell’s palsy during pregnancy should be evaluated critically as in some it may precede preeclampsia which has serious maternal and fetal implications. Therefore, these women should be in regular followup of the obstetrician. Vani Aditya Copyright © 2014 Vani Aditya. All rights reserved. A Case of Mucinous Cystadenofibroma of the Ovary Mon, 17 Mar 2014 09:39:04 +0000 Ovarian adenofibroma is a rare benign tumour originating from the germinal lining and stroma of the ovary. We describe here the case of a 36-year-old woman with an ovarian mucinous cystadenofibroma that was diagnosed as a benign cystic mass of the ovary before surgery. The tumour was a cystic lesion composed of 2 regions: one filled with mucinous fluid and the other with yellowish solid components. The patient successfully underwent a left oophorectomy. Dae Hyung Lee Copyright © 2014 Dae Hyung Lee. All rights reserved. Conservative Treatment of Stage IA1 Adenocarcinoma of the Uterine Cervix during Pregnancy: Case Report and Review of the Literature Sun, 16 Mar 2014 11:37:32 +0000 Microinvasive adenocarcinoma (MIAC) of the uterine cervix is rare in pregnancy. Published data on conservative treatment of MIAC both in pregnant and nonpregnant women are scarce. A conservatively treated case of MIAC in a 13-week-pregnant woman after a diagnosis of atypical glandular cells (AGC) on pap smear at the 6th week of pregnancy is presented. The problems of suspected adenocarcinoma in situ (AIS) on biopsy and MIAC on cone biopsy in pregnancy, as well as the risks and benefits of a conservative treatment are discussed. After colposcopic guide laser cervical conization and expression of informed consent the patient underwent followup and vaginal delivery at 40 weeks plus 3 days of gestation. In this case, no obstetric complication has been recorded after the cervical conization, and after a followup of 18 months the patient was alive and free of disease, with negative results as far as pap smear, colposcopy, HPV status, and cervical curettage are concerned. In a stage Ia1 disease of endocervical type, with clear margins and without lymph-vascular space invasion, cervical conization performed during the second trimester may be considered a definitive and safe treatment, at least up to delivery, after expression of informed consent by the woman. Francesco Sopracordevole, Diego Rossi, Jacopo Di Giuseppe, Marta Angelini, Pierino Boschian-Bailo, Monica Buttignol, and Andrea Ciavattini Copyright © 2014 Francesco Sopracordevole et al. All rights reserved. Multicystic Benign Cystic Mesothelioma Presenting as a Pelvic Mass Wed, 12 Mar 2014 13:17:02 +0000 Background. Benign cystic mesothelioma (BCM) is a rare tumor that arises from the abdominal peritoneum with a predilection to the pelvic peritoneum. For this reason, it can often mimic gynecologic malignancies. Case. A 47-year-old perimenopausal female presented reporting several weeks of abdominal distention associated with abdominal tenderness and constipation. Computed tomography revealed a 24 cm multiloculated pelvic mass, and tumor markers were notable for an elevated CA-125. The patient was taken to the operating room for an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingoophorectomy, and removal of pelvic mass. Final pathologic evaluation revealed a benign cystic mesothelioma. Conclusion. Classically these tumors present as large multicystic masses with thin-walled septations and on preoperative evaluation BCM can mimic many different disease entities including ovarian malignancies and cystic lymphangioma. Often diagnosis can only be made at time of surgery. Mazdak Momeni, Elena Pereira, Gennadiy Grigoryan, and Konstantin Zakashansky Copyright © 2014 Mazdak Momeni et al. All rights reserved. Necrotizing Fasciitis Complicating Pregnancy: A Case Report and Literature Review Sun, 09 Mar 2014 16:04:02 +0000 Necrotizing fasciitis is a rare, life-threatening surgical infection in pregnancy with high rates of morbidity and mortality. A 15-year-old primigravid woman, at 28 weeks of gestation with no significant previous medical history, was admitted to our hospital complaining of severe left lower extremity pain and high fever the last 72 hours. During clinical examination, she had a swollen, erythematous and tender to palpation inflamed skin over the medial aspect of the upper thigh without any evidence of injury. Incision drainage was performed immediately and she received broad spectrum antibiotics. During initial laboratory examinations, diabetes mellitus was diagnosed. There was no clinical improvement over the following days. Magnetic resonance imaging (MRI) revealed subcutaneous tissue inflammation and edema of infected tissues confirming the disease entity. Multidisciplinary therapy with immediate aggressive surgical debridement of necrotic tissues, multiple antibiotics, and intensive care monitoring was performed successfully. The patient’s postoperative course was uncomplicated and skin defect was closed with split thickness skin grafting. Our case emphasized the potential immunosuppressive role of pregnancy state in conjunction with diabetes mellitus in the development of severe necrotizing soft tissue infections. Marinos Nikolaou, Petros Zampakis, Vasiliki Vervita, Konstantinos Almaloglou, Georgios Adonakis, Markos Marangos, and Georgios Decavalas Copyright © 2014 Marinos Nikolaou et al. All rights reserved. Prolapse of the Small Intestine from the Uterine Perforation at Dilatation and Curettage Tue, 04 Mar 2014 12:45:03 +0000 Dilatation and curettage (D&C) sometimes causes uterine perforation, which usually does not cause a serious problem. Here, we report uterine perforation caused by D&C, in which the small intestine prolapsed from the uterus, requiring intestinal resection. D&C was performed for missed abortion at 9 weeks. After dilating the cervix, forceps grasped tissue that, upon being pulled, resulted in the intestine being prolapsed into the vagina. Laparotomy revealed a perforation at the low anterior uterine wall, through which the ileum had prolapsed. The mesentery of the prolapsed ileum was completely detached and the ileum was necrotic, which was resected. The uterus and the intestine were reconstructed. Although intestinal prolapse is considered to be caused by “unsafe” D&C performed by inexperienced persons or even by nonphysicians in developing countries, this occurred in a tertiary center of a developed country. We must be aware that adverse events such as uterine perforation with intestinal prolapse can occur even during routine D&C. Shigeki Matsubara, Akihide Ohkuchi, Hiroaki Nonaka, Homare Ito, and Alan T. Lefor Copyright © 2014 Shigeki Matsubara et al. All rights reserved. Laparotomic Myomectomy in the 16th Week of Pregnancy: A Case Report Tue, 04 Mar 2014 08:42:44 +0000 Myomectomy is rarely performed during an ongoing pregnancy because of fear of miscarriage and the risk of an uncontrolled haemorrhage necessitating a hysterectomy. In cases where myomectomy is undertaken, most are performed at the time of cesarean section or with a laparoscopic approach. We report a case of a successful laparotomic myomectomy in the 16th week of pregnancy. A 35-year-old primigravida was admitted to our department with acute abdominal pain and hydronephrosis (serum creatinine 1.6 mg/dL). Imaging revealed a large implant myoma compressing the bladder, ureters, rectus, and gestational chamber and causing hydronephrosis. Laparotomic myomectomy was successfully performed and pregnancy continued uneventfully until the 38th week when a cesarean section was performed. Surgical management of myomas during pregnancy is worth evaluating in well-selected and highly symptomatic cases. Lavinia Domenici, Violante Di Donato, Maria Luisa Gasparri, Francesca Lecce, Jlenia Caccetta, and Pierluigi Benedetti Panici Copyright © 2014 Lavinia Domenici et al. All rights reserved. Fatal Disseminated Tuberculous Peritonitis following Spontaneous Abortion: A Case Report Tue, 04 Mar 2014 08:30:57 +0000 We describe a rare case of fatal disseminated tuberculous peritonitis in a young woman with rapid progressive clinical course following spontaneous abortion of 20-week gestation. Clinical and laboratory findings were initially unremarkable. She underwent diagnostic laparoscopy which revealed numerous tiny implants on the peritoneum and viscera. Histopathology showed chronic caseating granulomas, and the tissue culture grew Mycobacterium tuberculosis. At fifth day of the antituberculous treatment multiorgan failure occurred in terms of pulmonary, hepatic, and renal insufficiency. She developed refractory metabolic acidosis with coagulopathy and pancytopenia, and she died of acute respiratory distress syndrome and septic shock on her twelfth day of hospitalization. Munire Erman Akar, Tayfun Toptas, Havva Sutcu, Haney Durmus, Murat Ozekinci, Melike Cengiz, and Gulgun Erdogan Copyright © 2014 Munire Erman Akar et al. All rights reserved. Obstructive Small Bowel Metastasis from Uterine Leiomyosarcoma: A Case Report Tue, 04 Mar 2014 07:39:46 +0000 Background. Uterine leiomyosarcoma is a rare and aggressive gynecologic malignancy with an overall poor prognosis. Lungs, bones, and brain are common sites of metastases of uterine leiomyosarcoma. Metastases of uterine leiomyosarcoma to the small bowel are extremely rare, and only four case reports have been published to date. Case presentation. A 55-year-old Saudi woman diagnosed with a case of uterine leiomyosarcoma treated with total abdominal hysterectomy (TAH) and bilateral salpingooophorectomy (BSO) presented in emergency room after sixteen months with acute abdomen. Subsequent work-up showed a jejunal mass for which resection and end-to-end anastomosis were performed. Biopsy confirmed the diagnosis of small bowel metastasis from uterine leiomyosarcoma. Further staging work-up showed wide spread metastasis in lungs and brain. After palliative cranial irradiation, systemic chemotherapy based on single agent doxorubicin was started. Conclusion. Metastatic leiomyosarcoma of small bowel from uterine leiomyosarcoma is a rare entity and is sign of advanced disease. It should be differentiated from primary leiomyosarcoma of small bowel as both are treated with different systemic chemotherapeutic agents. Mutahir A. Tunio, Mushabbab AlAsiri, Rasha M. Saleh, Shomaila Amir Akbar, Nagoud M. Ali, and Mohamed Abdalazez Senosy Hassan Copyright © 2014 Mutahir A. Tunio et al. All rights reserved. Four Cases of Chylous Ascites following Robotic Gynecologic Oncological Surgery Tue, 04 Mar 2014 07:35:40 +0000 Chylous ascites is an uncommon form of ascites characterized by milky-appearing fluid caused by blocked or disrupted lymph flow through chyle-transporting vessels. The most common causes of chylous ascites are therapeutic interventions and trauma. In this report, we present four cases of chylous ascites following robot-assisted surgery for endometrial staging and the treatment strategies that we used. After retroperitoneal lymph node dissection, leaving a drain is very useful in diagnosing chylous ascites and observing its resolution; furthermore, the use of octreotide in conjunction with TPN appears to be an efficient treatment modality for chylous ascites and should be considered before any invasive intervention. Ahmet Göçmen, Muhittin Eftal Avcı, Fatih Şanlıkan, and Mustafa Gazi Uçar Copyright © 2014 Ahmet Göçmen et al. All rights reserved. A Rare Coexistence of Villoglandular Papillary Adenocarcinoma of the Uterine Cervix and Brenner Tumor of the Ovary Sun, 23 Feb 2014 08:41:48 +0000 Synchronous primary gynecological cancers have been reported to be seen rarely in the literature. In this report, we aimed to describe a 51-year-old patient with the coexistence of villoglandular papillary adenocarcinoma of the cervix uteri and Brenner tumor in the right ovary. She successfully underwent radical hysterectomy, bilateral salphing-oopherectomy and pelvic and para-aortic lymphadenectomy. Kadir Guzin, Sadik Sahin, Gokhan Goynumer, Mustafa Eroğlu, Akın Usta, and Nurver Ozel Copyright © 2014 Kadir Guzin et al. All rights reserved. Complication of Invasive Molar Pregnancy with Clostridium perfringens Sepsis Thu, 13 Feb 2014 10:00:42 +0000 Clostridium perfringens (CP) is an anaerobic, Gram-positive bacillus associated with malignant diseases and near-term pregnancies. The necrotic tissue that results from these disease processes fuels the proliferation of CP, leading to gas gangrene and subsequently sepsis. Herein, we report a case of a 41-year-old female patient with a history of invasive molar pregnancy that was further complicated with a CP infection. Although past research has shown a link between Clostridium infection and choriocarcinoma (Chern-Horng and Hsieh, 1999), no previous cases of CP infection have been associated with invasive molar pregnancy. We also report complete resolution of the CP sepsis and its associated symptoms following the hysterectomy. Sanmeet Singh, Kunal Angra, Bonnie Davis, and Babak Shokrani Copyright © 2014 Sanmeet Singh et al. All rights reserved. Pyoderma Gangrenosum in Two Successive Pregnancies Complicating Caesarean Wound Tue, 11 Feb 2014 13:17:59 +0000 Pyoderma gangrenosum (PG) is a rare ulcerative cutaneous disorder with tendency to recur in the injured area. Though most of the time is associated with chronic systemic conditions, it can occur in isolation and can be a diagnostic dilemma. The aetiology is poorly understood. The diagnosis is based on clinical features and excluding other causes of skin ulcers, as it does not have characteristic histopathology or laboratory findings. Lesions can develop after surgery, after trauma or de novo. We are reporting a 32-year-old pregnant lady with two previous instances of pyoderma gangrenosum in the previous pregnancy, who in postoperative period following caesarean section developed the same condition for the third time. She responded well to local wound care, oral Prednisolone, and Dapsone and made a good recovery. Pregnancy being an immunologically altered status can play a role in development of pyoderma gangrenosum and one should always rule out its possibility when there is a delayed wound healing. Sapna Vinit Amin, Neha Bajapai, Ashwini Pai, Sunanda Bharatnur, and Shripad Hebbar Copyright © 2014 Sapna Vinit Amin et al. All rights reserved. The Phantom Urine: An Unexpected Finding during a Routine Cesarean Section Tue, 11 Feb 2014 06:17:53 +0000 We present here an atypical finding during an elective repeat cesarean section. Despite urine flow through an indwelling bladder catheter, bladder remains distended during the whole procedure. Unexpected anatomical variations and malformations can make routine surgery challenging. Urinary tract anomalies should be suspected in cases of unexpected difficult bladder catheterization. Maria Pagnozza, Chahin Achtari, Jean-Yves Meuwly, and David Baud Copyright © 2014 Maria Pagnozza et al. All rights reserved. Concomitant Imperforate Hymen and Transverse Vaginal Septum Complicated with Pyocolpos and Abdominovaginal Fistula Mon, 10 Feb 2014 13:13:45 +0000 A 13-year-old patient with a complaint of worsening lower abdominal pain during the past 4 months was admitted to the emergency department. An abdominopelvic ultrasound scan revealed a distended uterocervical cavity suggestive of hematometrocolpos. Imperforate hymen was observed on examination of the external genitalia. MRI scan revealed an air-fluid level representing pyometrocolpos within a distended vagina. Posterior vaginal extraperitoneal leakage as the sign of a fistula between the vagina and the rectovaginal space was detected. Although laparoscopic approach was planned, malodorous pus expelled after the insertion of the Veress needle, it was decided to proceed to laparotomy. Pus with peritoneal microabscess formations was observed at laparotomy. The imperforate hymen and TVS were excised vaginally. A more complex anomaly should be suspected in cases with hematometra and concomitant imperforated hymen without any bulging and thorough evaluation using radiological imaging techniques should be performed before surgical approach. Berna Dilbaz, Sadiman Kiykac Altinbas, Namik Kemal Altinbas, Ozlem Sengul, and Serdar Dilbaz Copyright © 2014 Berna Dilbaz et al. All rights reserved. Leiomyoma in Vulva: A Diagnostic Dilemma Mon, 10 Feb 2014 09:34:09 +0000 With the help of this case we summarize some crucial features to be picked up from history and examination before labeling a case as Bartholin’s abscess or cyst. A 20-year old unmarried girl, deaf and mute since birth, was initially diagnosed to have Bartholin’s abscess. On careful reexamination after inflammation subsided, a decision of excision of this tumor was taken. Intraoperatively it was found to be well encapsulated. Histopathology ascertained the diagnosis of vulval leiomyoma. Deeksha Pandey, Jyothi Shetty, Aashish Saxena, and P. S. Srilatha Copyright © 2014 Deeksha Pandey et al. All rights reserved. A Case of Endometrioid Adenocarcinoma Arising from Adenomyosis Mon, 10 Feb 2014 00:00:00 +0000 Malignant changes in endometriosis are often reported, but those in adenomyosis are rare. We report a case of endometrioid adenocarcinoma arising from adenomyosis. Case Presentation. A 57-year-old woman presenting with vaginal bleeding was referred to our hospital. Cytological tests of endometrium revealed atypical glandular cells. Fractional endometrial curettage revealed normal endometrium without atypia. Magnetic resonance imaging (MRI) revealed multiple myomas. The endometrium was slightly enhanced on T1-weighted imaging and endometrial cancer was suspected. Myometrial invasion was not evident. The patient was admitted and semiradical hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy was performed. Histopathological study revealed grade 1 endometrioid adenocarcinoma. Although the lesion was located in the muscle layer of the corpus and invaded more than half of it, the endometrium was intact. Pelvic lymph node metastasis was noticed. No cervical invasion or metastasis to the adnexa was seen. We diagnosed the case with a stage 1B endometrioid adenocarcinoma originating from adenomyosis. Adjuvant chemotherapy was then performed in the form of 5 cycles of paclitaxel (180 mg/m2) and carboplatin (AUC = 5). Five years later, right lung metastasis and right para-aortic and pelvic lymph nodes metastasis were noticed. Paclitaxel and carboplatin are now being administered. Shigeki Taga, Mari Sawada, Aya Nagai, Dan Yamamoto, and Ryoji Hayase Copyright © 2014 Shigeki Taga et al. All rights reserved.