Case Reports in Obstetrics and Gynecology The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. First Described Case of Group B Streptococcus Pelvic Abscess in a Patient with No Medical Comorbidities Wed, 27 Jul 2016 12:02:42 +0000 Background. Group B Streptococcus is an organism that commonly infects a wide range of hosts including infants in the first week of life, pregnant women, and older age adults as well as adults with underlying medical comorbidities. Case. Large pelvic abscess in a nonpregnant patient found to be caused by Group B Streptococcus was treated successfully with IR guided drainage and antibiotics. Conclusion. Though rare, GBS can still be a cause of invasive infection even in individuals who are nonpregnant and have no underlying comorbidities. Empiric antibiotic coverage for this organism should be kept in mind when treating an abscess. Paul Tyan, Elias Abi-Khalil, Karthik Dwarki, and Gaby Moawad Copyright © 2016 Paul Tyan et al. All rights reserved. Spontaneous Bilateral Tubal Gestation: A Rare Case Report Sun, 17 Jul 2016 13:36:07 +0000 Here a case is presented where the woman after a positive pregnancy test underwent medical abortion for unwanted pregnancy without ultrasound confirmation of intrauterine pregnancy. On persistence of symptoms, a second opinion was procured, when examination and a transvaginal ultrasound scan revealed ruptured unilateral tubal ectopic pregnancy. However upon subsequent laparotomy (considering deteriorating hemodynamic status of the patient), intraoperatively it turned out to be a bilateral tubal ectopic gestation. Marwah Sheeba and Gupta Supriya Copyright © 2016 Marwah Sheeba and Gupta Supriya. All rights reserved. Resuscitating the Baby after Shoulder Dystocia Thu, 14 Jul 2016 08:57:37 +0000 Background. To propose hypovolemic shock as a possible explanation for the failure to resuscitate some babies after shoulder dystocia and to suggest a change in clinical practice. Case Presentation. Two cases are presented in which severe shoulder dystocia was resolved within five minutes. Both babies were born without a heartbeat. Despite standard resuscitation by expert neonatologists, no heartbeat was obtained until volume resuscitation was started, at 25 minutes in the first case and 11 minutes in the second. After volume resuscitation circulation was restored, there was profound brain damage and the babies died. Conclusion. Unsuspected hypovolemic shock may explain some cases of failed resuscitation after shoulder dystocia. This may require a change in clinical practice. Rather than immediately clamping the cord after the baby is delivered, it is proposed that (1) the obstetrician delay cord clamping to allow autotransfusion of the baby from the placenta and (2) the neonatal resuscitators give volume much sooner. Savas Menticoglou and Carol Schneider Copyright © 2016 Savas Menticoglou and Carol Schneider. All rights reserved. A Case of New-Onset Dermatomyositis in the Second Trimester of Pregnancy: A Case Report and Review of the Literature Sun, 10 Jul 2016 14:15:01 +0000 Dermatomyositis (DM), a subtype of idiopathic inflammatory myopathies (IIMs), is characterized by skin rash, proximal muscle weakness, and inflammatory infiltrates in the muscle tissue. The peak incidence of the disease is at the age of 50–60 years, and only 14% of the patients with IIMs are estimated to present during reproductive years. Because of the limited pregnancy experience in patients with IIMs, little is known regarding the effects of DM on pregnancy or vice versa. We herein report a 40-year-old woman who developed DM in the second trimester of her pregnancy and did not respond to treatment with methylprednisolone. Her pregnancy was terminated at the 32nd week of gestation, due to preeclampsia and fetal distress. She delivered a healthy baby and improved rapidly after delivery. We have searched PubMed for relevant articles and reviewed previously published cases. Tayfun Akalin, Hatice Akkaya, Barış Büke, and İbrahim Koçak Copyright © 2016 Tayfun Akalin et al. All rights reserved. Perinatal Management for a Pregnant Woman with an MYH9 Disorder Wed, 29 Jun 2016 09:55:37 +0000 We diagnosed a primipara woman with an MYH9 disorder during her pregnancy. A peripheral blood smear with an immunofluorescence analysis is the established method of diagnosing MYH9 disorders. We provided genetic counseling, as required, which included apprising the woman of the inheritance pattern, the importance of a genetic analysis, and the potential delivery risks for the patient and her offspring. Given that the potential delivery risks are reportedly low, special perinatal management is not necessary for patients with an MYH9 disorder whose platelet count is above 5.0 × 104/μL, except for rapid blood access. Yuka Yamashita, Rei Matsuura, Shinji Kunishima, Yoshie Oikawa, Hirotsugu Ariizumi, Shoko Hamada, Nahoko Shirato, Ryu Matsuoka, Kohichi Ogawa, and Akihiko Sekizawa Copyright © 2016 Yuka Yamashita et al. All rights reserved. Spontaneous Heterotopic Pregnancy: Dual Case Report and Review of Literature Sun, 19 Jun 2016 10:19:18 +0000 Introduction. Heterotopic pregnancy is a rare complication usually seen in populations at risk for ectopic pregnancy or those undergoing fertility treatments. It is a potentially dangerous condition occurring in only 1 in 30,000 spontaneous pregnancies. With the advent of Assisted Reproduction Techniques (ART) and ovulation induction, the overall incidence of heterotopic pregnancy has risen to approximately 1 in 3,900 pregnancies. Other risk factors include a history of pelvic inflammatory disease (PID), tubal damage, pelvic surgery, uterine Mullerian abnormalities, and prior tubal surgery. Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. Most commonly, heterotopic pregnancy is diagnosed at the time of rupture when surgical management is required. Case. This paper represents two cases of heterotopic pregnancies as well as a literature review. Conclusion. Heterotopic pregnancy should be suspected in patients with an adnexal mass, even in the absence of risk factors. Clinicians must be alert to the fact that confirming an intrauterine pregnancy clinically or by ultrasound does not exclude the coexistence of an ectopic pregnancy. A high index of suspicion in women is needed for early and timely diagnosis, and management with laparotomy or laparoscopy can result in a favorable and successful obstetrical outcome. Annika Chadee, Shadi Rezai, Catherine Kirby, Ekaterina Chadwick, Sri Gottimukkala, Abraham Hamaoui, Vasiliy Stankovich, Theodore Hale, Hamid Gilak, Mohammad Momtaz, Harvey Sasken, and Cassandra E. Henderson Copyright © 2016 Annika Chadee et al. All rights reserved. Arteriovenous Fistula Embolization in Suspected Parauterine Choriocarcinoma Tue, 14 Jun 2016 10:25:17 +0000 This is a case of choriocarcinoma that did not regress after chemotherapy treatment. A 30-year-old female patient (gravida 2, para 2), presented to our ER with stroke and persistent mild pelvic pain 2 months after a Caesarean section. Computed tomography (CT) revealed an ischemic left hemicerebellar region and a hypervascular mass in the pelvic region. This mass was not present on routine fetal ultrasound during pregnancy. The lesion was treated by chemotherapy after closure of a foramen ovale and insertion of an inferior vena cava (IVC) filter. After that, 2 courses of EMACO (Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide, and Vincristine) chemotherapy regimen were given. Posttreatment CT showed the hypervascular mass without any changes. Arteriography showed the arteriovenous fistulae that were embolized successfully with plugs, coils, and glue. Embolization was considered due to the risk of acute hemorrhagic life-threatening complications. Eight chemotherapy courses were added after embolization. Treatment by endovascular approach and reduction of the hypervascular mass can be a valuable adjunct to chemotherapy treatment of choriocarcinoma. Husain Alturkistani, Mohamed-Karji Almarzooqi, Vincent Oliva, and Patrick Gilbert Copyright © 2016 Husain Alturkistani et al. All rights reserved. Metastatic Malignant Ovarian Steroid Cell Tumor: A Case Report and Review of the Literature Wed, 08 Jun 2016 07:36:19 +0000 We report a case of malignant ovarian steroid cell tumor not otherwise specified (NOS) in a 47-year-old female who presented with hirsutism, virilization, and amenorrhea. At the time of laparotomy, the tumor had already spread to the pelvic cul-de-sac. She underwent a total hysterectomy, bilateral salpingo-oophorectomy, and tumor resection with no residual disease. She received three cycles of bleomycin, etoposide, and cisplatin (BEP) and is now free of disease 24 months after surgery. Literature review of ovarian steroid cell tumors NOS including clinicopathological features and clinical management was performed. Jessica Lee, Veena S. John, Sharon X. Liang, Catherine A. D’Agostino, and Andrew W. Menzin Copyright © 2016 Jessica Lee et al. All rights reserved. Placenta Increta Complicating Persistent Cesarean Scar Ectopic Pregnancy following Failed Excision with Subsequent Preterm Cesarean Hysterectomy Tue, 07 Jun 2016 12:23:30 +0000 Introduction. Cesarean scar pregnancies (CSPs) are one of the rarest forms of ectopic pregnancy. Given their rarity, there is lack of consensus regarding the management and natural course of CSPs. Case. A 37-year-old G10 P3063 female with a history of two prior cesarean deliveries was diagnosed with her second CSP at 6 weeks and 5 days in her tenth pregnancy. The patient underwent vertical hysterotomy, excision of a gestational sac implanted in the cesarean sac, and bilateral salpingectomy via a laparotomy incision. The histopathology report confirmed immature chorionic villi. The patient returned 10 weeks later and was found to be still pregnant. Obstetric ultrasound confirmed a viable fetus of 19 weeks and 4 days of gestational age with a thin endometrium and an anteroposterior and right lateral placenta with multiple placental lakes. The patient ruptured her membranes at 31 weeks of gestation and pelvic MRI revealed an anterior placenta invading the myometrium and extending to the external serosal surface consistent with placenta increta. Following obstetric interventions, a live female infant was delivered by cesarean hysterectomy (because of placenta increta) at 32 weeks of gestation. Conclusion. Development of standardized guidelines for management of CSPs, as well as heightened vigilance for possible complications, is required for proper care and avoidance of potential morbidity and mortality. M. F. Malik, L. R. Hoyos, J. Rodriguez-Kovacs, J. Gillum, and S. C. Johnson Copyright © 2016 M. F. Malik et al. All rights reserved. Nonobstructive Acute Renal Failure with a Large Solitary Fibroid Tue, 07 Jun 2016 08:53:03 +0000 A 38-year-old African American woman presenting with acute abdominal pain and nonobstructive renal failure was found to have an enlarged fibroid uterus. A differential for sepsis was considered. Lab evaluation revealed an elevated creatinine and myoglobin level at 3.9 mg/dL and 2140 ng/mL, respectively. Ongoing hemodynamic instability mandated surgery for acute abdomen. A 25 cm fibroid uterus was extirpated through a total abdominal hysterectomy. Immediate improvement of acute nephropathy mirrored the postoperative decline in serum myoglobin levels. Myoglobinemia from a massive degenerating fibroid is associated with nonobstructive acute renal failure. Rayan Elkattah, Zineb Mashak, Blakele Bakker, Shanti Mohling, Ali Yilmaz, Stephen DePasquale, and Todd Boren Copyright © 2016 Rayan Elkattah et al. All rights reserved. Dicephalus Parapagus Conjoined Twins Diagnosed by First-Trimester Ultrasound Sun, 05 Jun 2016 07:40:27 +0000 Conjoined twins are a rare phenomenon, occurring in 1% of monochorionic twin gestation, with an incidence of 1 : 50 000 to 1 : 100 000. Many conjoined twins have abnormalities incompatible with life, so early prenatal diagnosis is very important for optimal management of both pregnancy and delivery. We report a case of dicephalus parapagus conjoined twins, sharing a single heart, diagnosed at 12 weeks’ gestation. With early ultrasound diagnosis, we were able to provide appropriate and timely prenatal counseling to the family. Keiko Watanabe, Masanori Ono, Mayu Shirahashi, Toshiyuki Ikeda, and Kazumi Yakubo Copyright © 2016 Keiko Watanabe et al. All rights reserved. Thrombocytopenia and Postpartum Hemorrhage in a Woman with Chromosome 22q11.2 Deletion Syndrome Sun, 05 Jun 2016 07:39:02 +0000 Chromosome 22q11.2 deletion syndrome, also known as DiGeorge or velocardiofacial syndrome, is associated with a wide spectrum of phenotypic features. It is known to be associated with severe macrothrombocytopenia. Postpartum hemorrhage is a leading cause of maternal morbidity and mortality globally. Chromosome 22q11.2 deletion syndrome is rare cause of thrombocytopenia that can be a significant risk factor for life-threatening postpartum hemorrhage. We report a case of postpartum hemorrhage in a woman with 22q11.2 deletion syndrome causing severe macrothrombocytopenia. Sarah L. Pachtman, Kathy Deng, and Deepak Nanda Copyright © 2016 Sarah L. Pachtman et al. All rights reserved. Preeclampsia: A Possible Complication of Primary Hyperparathyroidism Thu, 02 Jun 2016 16:11:34 +0000 Background. Primary hyperparathyroidism is rare in pregnancy. An association between primary hyperparathyroidism and preeclampsia has been reported in few cases worldwide. Case. A 28-year-old woman (gravida 2, para 0, and abortus 1) in her 27th week of gestation was hospitalized due to a high reading of blood pressure (194/115 mmHg) that was not accompanied by any symptoms or signs of preeclampsia. Incidentally, she was found to have a high adjusted calcium and serum parathyroid hormone (PTH) level during admission. Ultrasonographic examination of the neck revealed the presence of parathyroid adenoma. She was scheduled for surgical excision after receiving an intravenous hydration. Fetal ultrasonography revealed a growth restricted fetus with normal biophysical profile. On the sixth day of hospitalization, the patient complained of headache and epigastric pain, with elevated BP and proteinuria. The fetal nonstress test was “nonreassuring.” Subsequently, she had an emergency cesarean delivery and surgical removal of the adenoma. The mother and her newborn were then transferred to intensive care, where their clinical course was unremarkable. The mother was discharged after 3 days, while the neonate stayed for close observation for 60 days. Conclusion. Early recognition of primary hyperparathyroidism among women with preeclampsia is important to prevent maternal and fetal morbidity and mortality. Bader Abdullah Alharbi, Mohammed Ali Alqahtani, Mohammed Hmoud, Essam Awadh Alhejaili, and Reema Badros Copyright © 2016 Bader Abdullah Alharbi et al. All rights reserved. Acute Intestinal Obstruction Complicating Abdominal Pregnancy: Conservative Management and Successful Outcome Thu, 26 May 2016 07:53:08 +0000 Background. Acute intestinal obstruction during pregnancy is a very challenging and unusual nonobstetric surgical entity often linked with considerable fetomaternal morbidity and mortality. When it is synchronous with abdominal pregnancy, it is even rarer. Case Presentation. A 28-year-old lady in her second pregnancy was referred to Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria, at 27 weeks of gestation due to vomiting, constipation, and abdominal pain. Examination and ultrasound scan revealed a single live intra-abdominal extrauterine fetus. Plain abdominal X-ray was diagnostic of intestinal obstruction. Conservative treatment was successful till the 34-week gestational age when she had exploratory laparotomy. At surgery, the amniotic sac was intact and the placenta was found to be adherent to the gut. There was also a live female baby with birth weight of 2.3 kg and Apgar scores of 9 and 10 in the 1st and 5th minutes, respectively, with the baby having right clubbed foot. Adhesiolysis and right adnexectomy were done. The mother and her baby were well and were discharged home nine days postoperatively. Conclusion. To the best of our knowledge, this is the first report of abdominal pregnancy as the cause of acute intestinal obstruction in the published literature. Management approach is multidisciplinary. Gerald Okanandu Udigwe, George Uchenna Eleje, Eric Chukwudi Ihekwoaba, Onyebuchi Izuchukwu Udegbunam, Richard Obinwanne Egeonu, and Ayodele Obianuju Okwuosa Copyright © 2016 Gerald Okanandu Udigwe et al. All rights reserved. A Giant Vulvar Mass: A Case Study of Cellular Angiofibroma Mon, 16 May 2016 10:53:25 +0000 Cellular angiofibroma is a mesenchymal tumor that affects both genders. Nucci et al. first described it in 1997. Cellular angiofibroma is generally a small and asymptomatic mass that primarily arises in the vulvar-vaginal region, although rare cases have been reported in the pelvic and extrapelvic regions. It affects women most often during the fifth decade of life. The treatment requires simple local excision due to low local recurrence and no chance of metastasization. The current study presents a case of angiofibroma in the vulvar region that measured approximately 20 cm. Ümit Aydın, Hasan Terzi, Ünal Turkay, Ahmet Tuğrul Eruyar, and Ahmet Kale Copyright © 2016 Ümit Aydın et al. All rights reserved. Lipoyltransferase 1 Gene Defect Resulting in Fatal Lactic Acidosis in Two Siblings Tue, 10 May 2016 14:15:31 +0000 A term male neonate developed severe intractable lactic acidosis on day of life 1 and died the same day at our institution. The family previously lost another term, female newborn on day of life 1 from suspected sepsis at an outside hospital. After performing an autopsy on the neonate who died at our institution, extensive and lengthy neonatal and parental genetic testing, as well as biochemical analyses, and whole exome sequencing analysis identified compound heterozygous mutations in the lipoyltransferase 1 (LIPT1) gene responsible for the lipoylation of the 2-keto dehydrogenase complexes in the proband. These mutations were also identified in the deceased sibling. The clinical manifestations of these two siblings are consistent with those recently described in two unrelated families with lactic acidosis due to LIPT1 mutations, an underrecognized and underreported cause of neonatal death. Conclusions. Our observations contribute to the delineation of a new autosomal recessive metabolic disorder, leading to neonatal death. Our case report also highlights the importance of an interdisciplinary team in solving challenging cases. Véronique Taché, Liga Bivina, Sophie White, Jeffrey Gregg, Joshua Deignan, Simeon A. Boyadjievd, and Francis R. Poulain Copyright © 2016 Véronique Taché et al. All rights reserved. Primary Umbilical Endometriosis: Unusual and Rare Clinical Presentation Sun, 08 May 2016 13:50:26 +0000 Primary umbilical endometriosis is a rare disorder and is defined as the presence of ectopic endometrial tissue within the umbilicus. A patient with painful mass in the umbilicus during menstrual period is studied in this paper. The possibility of subcutaneous endometriosis should be considered when an umbilical mass is detected despite the absence of previous surgery. In this case, urachal cancer, urachal remnant, umbilical endometriosis, and its malignant transformation were among the diseases considered in the differential diagnosis. Complete excision and histology are necessary to obtain a definitive diagnosis and optimal treatment for umbilical subcutaneous endometriosis. Fuminori Taniguchi, Eriko Hirakawa, Yukihiro Azuma, Chihiro Uejima, Keigo Ashida, and Tasuku Harada Copyright © 2016 Fuminori Taniguchi et al. All rights reserved. Aggressive Angiomyxoma in Pregnancy: A Rare Condition, a Common Misdiagnosis Thu, 05 May 2016 09:58:47 +0000 Introduction. Aggressive angiomyxoma is a rare mesenchymal neoplasm. Although benign in the majority of the cases, these neoplasms usually present a locally infiltrative nature and high rates of recurrence. Due to its rarity, misdiagnosis is a common problem. Case Presentation. We present one case of aggressive angiomyxoma in a 25-year-old pregnant woman. The patient presented with a large vaginal mass that was interpreted as a vaginal cyst. We performed surgical resection of the neoplasm and the correct diagnosis was only achieved after histological examination. With this case, we highlight the importance of considering this diagnosis in patients with genital and perineal masses of unknown origin and the impact of a correct preoperative diagnosis in patient’s management and follow-up. Conclusion. Although aggressive angiomyxoma is rare, it should be considered in differential diagnosis of pelviperineal masses in young women. Its positivity to estrogen and progesterone receptors can justify enlargement and recurrence during pregnancy, although few cases are reported. Early recognition demands high index of suspicion for both gynaecologists and pathologists. Wide surgical excision with tumor free margins is the basis of curative treatment. Adjuvant therapy may be necessary for residual or recurrent tumors. Long-term follow-up is recommended. J. Sampaio, I. Sarmento-Gonçalves, D. Ramada, T. Amaro, and P. Tiago-Silva Copyright © 2016 J. Sampaio et al. All rights reserved. Retracted: Prenatal Diagnosis of Concurrent Achondroplasia and Klinefelter Syndrome Thu, 28 Apr 2016 11:36:14 +0000 Case Reports in Obstetrics and Gynecology Copyright © 2016 Case Reports in Obstetrics and Gynecology. All rights reserved. Low-Grade Endometrial Stromal Sarcoma with Intravenous and Intracardiac Extension: A Multidisciplinary Approach Wed, 27 Apr 2016 16:13:08 +0000 Background. A rare case of low-grade endometrial stromal sarcoma (LG-ESS) extending to inferior vena cava (IVC) and cardiac chambers. Case Report. A 40-year-old woman had IVC tumor, which was incidentally detected by abdominal ultrasonography during a routine medical checkup. CT scan revealed a tumor in IVC, right iliac and ovarian veins, which was derived from the uterus and extended into the right atrium and ventricle. The operation was performed, the heart and IVC were exposed, and cardiopulmonary bypass was initiated. A right atriotomy was performed, and the intracardiac mass was removed. Then the tumor in IVC and the right internal iliac vein were removed after longitudinal venotomies in the suprarenal and infrarenal vena cava, the right common iliac vein. Next the pelvis was explored. Tumors were found originating from the posterior wall of the uterus and continuing into both the right uterine and ovarian vein. The patient underwent total hysterectomy with bilateral salpingooophorectomy. Complete tumor resection was achieved. Histopathological analysis confirmed a diagnosis of LG-ESS. She showed no evidence of disease for 2 years and 3 months. Conclusions. Our case highlights the importance of a multidisciplinary approach in treating this rare cardiovascular pathological condition through preoperative assessment to final operation. Wataru Kudaka, Hitoshi Inafuku, Yuko Iraha, Tomoko Nakamoto, Yusuke Taira, Rie Taira, Hisashi Kamiya, Maho Tsubakimoto, Yuichi Totsuka, Yukio Kuniyoshi, Tomoko Tamaki, Hajime Aoyama, Masanao Saio, Naoki Yoshimi, and Yoichi Aoki Copyright © 2016 Wataru Kudaka et al. All rights reserved. Conservative Resectoscopic Surgery, Successful Delivery, and 60 Months of Follow-Up in a Patient with Endometrial Stromal Tumor with Sex-Cord-Like Differentiation Tue, 26 Apr 2016 08:56:46 +0000 Uterine tumors with sex-cord-like differentiation are extremely rare types of uterine stromal neoplasm. These tumors were classified into two groups with considerable practical relevance because clinical behaviour of uterine tumor resembling ovarian sex cord tumor (UTROSCT) differs widely from its closely related endometrial stromal tumors with sex-cord-like elements (ESTSCLE). Treatment and prognosis of these tumors are unresolved issues because of the exiguous number of reported cases. We describe a rare case of endometrial stromal tumor with sex-cord-like differentiation successfully treated by resectoscopic surgery and conservation of the uterus, in an infertile patient affected by metrorrhagia. This procedure resulted in a pregnancy immediately after treatment and in a successful delivery. During 60 months of follow-up no evidence of recurrence was observed. Pasquale De Franciscis, Flavio Grauso, Domenico Ambrosio, Marco Torella, Enrico Michelino Messalli, and Nicola Colacurci Copyright © 2016 Pasquale De Franciscis et al. All rights reserved. A Successful Mother and Neonate Outcome for a Woman with Essential Thrombocytosis and FV Leiden Heterozygosity Thu, 31 Mar 2016 11:31:26 +0000 Essential thrombocytosis (ET) and FV Leiden heterozygosity represent an acquired and hereditable hypercoagulable state, respectively. An uncommon case of coexistence of ET and FV Leiden heterozygosity in a 36-year-old pregnant woman and her successful pregnancy outcome is described. She was considered to be at high risk of thrombosis during her pregnancy and she was treated with both prophylactic dose of LMWH and aspirin daily throughout her pregnancy and for a 6-week period postpartum. The efficacy of the anticoagulation treatment was monitored in various time points not only by measuring anti-Xa levels and D-Dimers but also with new coagulation methods such as rotation thromboelastometry and multiplate. Global assessment of coagulation using additional newer laboratory tests might prove useful in monitoring coagulation pregnancies at high risk for thrombosis. Marianna Politou, Serena Valsami, Irontianta Gkorezi-Ntavela, Vasilios Telonis, Efrosyni Merkouri, and Panagiotis Christopoulos Copyright © 2016 Marianna Politou et al. All rights reserved. Delayed Presentation of Vaginal Cuff Dehiscence after Robotic Hysterectomy for Gynecologic Cancer: A Case Series and Review of the Literature Sun, 27 Mar 2016 13:36:25 +0000 Background. Vaginal cuff dehiscence after hysterectomy has varying incidence according to surgical approach, with highest rates associated with laparoscopic surgery. Comparative data on timing of diagnosis describe a wide range of clinical presentation from weeks to years after hysterectomy. Limited reports have focused specifically on delayed presentation of vaginal cuff dehiscence. Cases. All cases of vaginal cuff dehiscence at our institution between 2005 and 2015 were collectively reviewed and three cases were identified of women who presented with cuff dehiscence greater than 180 days from index surgery. Diagnosis occurred at 342 to 461 days after operation. One patient presented with abdominal pain, a second case presented with vaginal discharge, and the third case lacked clinical symptoms altogether. Prior to diagnosis, one case received chemotherapy and external beam radiation for Stage IB1 cervical cancer and another case received external beam radiation alone for Stage II endometrioid adenocarcinoma. All cuffs were repaired vaginally with interrupted, early absorbable suture. Conclusion. Robotic total laparoscopic hysterectomy may be associated with increased risk of vaginal cuff dehiscence. Further studies are needed to determine risk factors and patient characteristics associated with delayed presentation of vaginal cuff dehiscence in robotic total hysterectomy as well as all surgical approaches. Pamela A. Escobar, Gregory M. Gressel, Gary L. Goldberg, and Dennis Yi-Shin Kuo Copyright © 2016 Pamela A. Escobar et al. All rights reserved. Unilateral Erythema Nodosum following Norethindrone Acetate, Ethinyl Estradiol, and Ferrous Fumarate Combination Therapy Sun, 27 Mar 2016 10:12:36 +0000 Erythema nodosum is a septal panniculitis that typically presents as symmetric, tender nodules on the anterior aspects of bilateral lower extremities. Nearly half of cases are due to secondary causes, with oral contraceptive pills being the leading pharmaceutical cause. However, to our knowledge, there has yet to be a published association with norethindrone acetate, ethinyl estradiol, and ferrous fumarate. We report our experience with a 30-year-old woman who developed unilateral tender nodules within a month of starting 1 mg norethindrone acetate and 20 mcg ethinyl estradiol daily. Of note, she had previously taken oral contraceptives with the same estrogen agent but different progesterone, without problems. We conclude that systemically triggered erythema nodosum can present with lesions localized to one extremity. When a patient presents with tender, firm nodules, clinicians should consider the possibility of erythema nodosum and its triggers, such as oral contraceptives. Additionally, should a patient on hormonal therapy develop erythema nodosum, changing the progesterone agent may allow the patient to continue similar therapy without developing symptoms. Michelle S. Min, Rob Fischer, and John B. Fournier Copyright © 2016 Michelle S. Min et al. All rights reserved. Recurrent Omental Hemangiopericytoma: A Therapeutic Challenge Mon, 21 Mar 2016 06:09:45 +0000 Hemangiopericytomas are vascular tumors with a susceptibility to arise anywhere in the human body. We present a case of a 68-year-old female with primary omental hemangiopericytoma and a two-time recurrence managed with surgery and close follow-up. The first recurrence was at 52 months and the second at 37 months following the prior presentation. No adjuvant chemotherapy or radiation therapy was administered. Given the widespread nature of the cell of origin, routine follow-up postoperatively with interval imaging in order to detect recurrences is imperative. Pathologic tumor characteristics may determine potential for recurrence and may also assist in determining whether adjuvant treatment modalities should be included in the management plan. Review of the English literature reveals a total of 24 cases of omental hemangiopericytomas inclusive of the current report. Sara Jaber, Ira Winer, and Nabila Rasool Copyright © 2016 Sara Jaber et al. All rights reserved. Uncommon Complication of Uterine Artery Embolization: Expulsion of Infarcted Myoma and Uterine Sepsis Thu, 17 Mar 2016 12:16:16 +0000 Uterine leiomyomas are the most common benign tumors in young females and leading cause of hysterectomy. Uterine artery embolization is a safe option for women who wish to retain their uterus. Several complications have been reported including expulsion and sepsis. MRI is a useful pretreatment tool to predict results and outcomes. We report a case of a 44-year-old female with a history of uterine fibroids with the largest one being intracavitary. Patient underwent uterine artery embolization that was complicated by endomyometritis that failed antibiotics, leading to sepsis and hysterectomy. Juliana G. Martins, Dawn Gaudenti, Frank Crespo, Dervi Ganesh, and Usha Verma Copyright © 2016 Juliana G. Martins et al. All rights reserved. Challenges in the Caesarean Section of a Severely Kyphotic Parturient Tue, 15 Mar 2016 16:57:56 +0000 Caesarean section in a severely kyphotic patient presents with unique challenges. We report a case of obstructed labor in case of a pregnant lady with severe kyphosis of spine that was managed by caesarean section. Lateral recumbent position with adequate assistance and paramedian or vertical skin incision was used and found to provide good exposure. Baby was delivered by lower segment uterine incision by reverse breech extraction. Postpartum hemorrhage was managed with uterotonics and bilateral uterine artery ligation. Tubal ligation though advised was refused by the patient. Prolonged catheterization was done in view of obstructed labor. Postoperative period was uneventful. Manisha Chhetry, Basudeb Banerjee, Shanti Subedi, Narayan Bahadur Gharti Chhetri, and Yogendra Gupta Copyright © 2016 Manisha Chhetry et al. All rights reserved. Ovarian Torsion in the Third Trimester of Pregnancy Leading to Iatrogenic Preterm Delivery Tue, 15 Mar 2016 09:38:25 +0000 Ovarian torsion in the third trimester of pregnancy leading to a midline laparotomy and caesarean section for the delivery of a preterm baby is an uncommon event. As the woman is likely to present with nonspecific symptoms of lower abdominal pain, nausea, and vomiting, ovarian torsion can often be misdiagnosed as appendicitis or preterm labour. Treatment and the opportunity to preserve the tube and ovary may consequently be delayed. We report the case of a multiparous woman who had undergone two previous caesarean sections at term, presenting at 35 weeks of gestation with a presumptive diagnosis of acute appendicitis. Ultrasonography described a cystic lesion 6 × 3 cm in the right adnexa, potentially a degenerating fibroid or a torted right ovary. MRI of the pelvis was unable to provide further clarity. The patient was managed by midline laparotomy and simultaneous detorsion of the ovarian pedicle and ovarian cystectomy together with caesarean section of a preterm infant. This report describes that prompt recognition and ensuring intraoperative access can achieve a successful maternal and fetal outcome in this rare and difficult scenario. Furthermore, we would like to emphasise that the risk for a pregnant woman and her newborn could be reduced by earlier diagnosis and management of ovarian masses (Krishnan et al., 2011). Evangelia Vlachodimitropoulou Koumoutsea, Manish Gupta, Antony Hollingworth, and Anwen Gorry Copyright © 2016 Evangelia Vlachodimitropoulou Koumoutsea et al. All rights reserved. A Case of Pyomyoma following Uterine Fibroid Embolization and a Review of the Literature Tue, 15 Mar 2016 09:37:30 +0000 Background. Since its introduction in 1996, uterine fibroid embolization (UFE) has become standard medical practice in the management of symptomatic uterine fibroids. An extremely rare complication, pyomyoma, has been reported only 5 times previously in the literature following UFE. Case. A 37-year-old woman underwent UFE for symptomatic leiomyomas of the uterus. Signs and symptoms of uterine infection ensued, beginning at 6 days following the procedure. Recurrent fevers and increasing leukocytosis despite the intravenous administration of appropriate antibiotics eventually necessitated surgical intervention on postprocedure day #18. Conclusion. An extremely rare complication of UFE is herein presented, pyomyoma, with a review of other reported cases. Commonalities are sought among these few reported cases with the hope of increasing diagnostic acumen in the detection of this disease. Chika C. Obele, Samantha Dunham, Genevieve Bennett, Johanna Pagan, Lok Yun Sung, and Hearns W. Charles Copyright © 2016 Chika C. Obele et al. All rights reserved. Torsion of a Subserosal Myoma Managed by Gasless Laparoendoscopic Single-Site Myomectomy with In-Bag Manual Extraction Sun, 13 Mar 2016 14:31:39 +0000 Acute torsion of a subserosal myoma is a rare surgical emergency that is infrequently diagnosed preoperatively. Furthermore, laparoendoscopic single-site (LESS) myomectomy with in-bag tissue extraction for the management of this disorder has not yet been described. A 43-year-old, gravida 1, para 1 woman was referred to our department due to a solid pelvic mass associated with persistent abdominal pain. A pedunculated subserosal myoma with torsion was strongly suspected based on ultrasonography and magnetic resonance imaging. Emergency LESS surgery showed that the subserosal myoma arising from the posterior uterine wall torted at its pedicle in the cul-de-sac. The twisted myoma node was excised by coagulation and cut using a LigaSure Atlas, followed by in-bag manual morcellation and extraction through an umbilical wound. The present case report emphasizes that LESS myomectomy with in-bag tissue extraction is a feasible minimally invasive surgical option for the management of subserosal myoma with torsion after a precise imaging-based diagnostic evaluation. Akihiro Takeda and Hiromi Nakamura Copyright © 2016 Akihiro Takeda and Hiromi Nakamura. All rights reserved.