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Case Reports in Obstetrics and Gynecology publishes case reports and case series related to obstetrics, maternal-fetal medicine, gynecology, gynecologic oncology, uro-gynecology, reproductive medicine, infertility, and reproductive endocrinology.
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Successful Oocyte Retrieval, Fertilization, and Clinical Pregnancy with Low Serum β-hCG on the Day of Oocyte Collection: A Reappraisal of the Definition of the Empty Follicle Syndrome
Objective. To describe a case of successful oocyte retrieval, fertilization and clinical pregnancy despite very low β-hCG level, twelve hours after ovulation trigger. Design. Case report. Setting. Academic medical center. Patient. A 38-year-old patient inadvertently administered 2,000 IU hCG for final oocyte maturation; serum hCG twelve hours later was 16 IU/L. Interventions. Effort to obtain and administer a booster dose of hCG over the next twenty-seven hours failed. Main Outcome. Successful oocyte retrieval. Results. Fourteen oocytes were retrieved of which twelve were in metaphase II and nine fertilized after intracytoplasmic sperm injection (ICSI). Of these, eight embryos survived to day 5 and were subjected to preimplantation genetic screening (PGS) by comparative genomic hybridization (CGH). Results were available the next day, three of the embryos were euploid and one was transferred on day 6. Pregnancy was confirmed twelve days later and currently the patient has an ongoing singleton intrauterine pregnancy. Conclusion. Reproductive Endocrinology and Infertility specialists should be aware that final oocyte maturation could occur following injection of a lower dose of hCG with excellent fertilization rate and embryo development.
Grade 4 Pneumonitis in a Patient Treated with a Combination of Gemcitabine and Docetaxel for Recurrent Leiomyosarcoma of the Uterus
Gemcitabine and docetaxel combination chemotherapy is the standard of care for patients with unresectable recurrent or metastatic leiomyosarcoma of the uterus. Although they are generally well-tolerated agents, they can also cause severe and life-threatening pulmonary toxicities. Here, we describe a case of grade 4 pneumonitis due to gemcitabine and docetaxel in a 74-year-old woman with recurrent, metastatic uterine leiomyosarcoma. Despite early recognition of chemotherapy-induced lung injury and early administration of corticosteroid, she developed noncardiogenic pulmonary edema, diffuse alveolar hemorrhage, and acute respiratory distress syndrome. She required multiple intubations and a tracheostomy. Physicians should not only be aware of gemcitabine and docetaxel’s potential to cause life-threatening pulmonary injuries but also recognize the variability in clinical presentations and treatment responses, the radiographic findings of these lung toxicities, and the need for early corticosteroid therapy in these cases.
Plasmapheresis for the Treatment of Anti-M Alloimmunization in Pregnancy
Intrauterine transfusion is the standard antenatal treatment for a fetus with severe anemia. Plasmapheresis is an alternative treatment for cases with a history of severe hemolytic disease of the fetus and newborns at less than 20 weeks of gestation. There is only one previous report of plasmapheresis for the anti-M alloimmunization in pregnancy, and we report here on the successful treatment of plasmapheresis for anti-M alloimmunization. A woman with a history of intrauterine fetal death at 24 weeks of gestation due to severe fetal anemia caused by anti-M alloimmunization received plasmapheresis once or twice a week from 14 weeks of gestation onward. An intrauterine blood transfusion was conducted at 28 weeks, and a cesarean section was performed at 31 weeks. The infant had anemia and jaundice but was discharged at day 46. Plasmapheresis may delay the development of fetal anemia and reduce the risk of early and repeat intrauterine transfusion in cases of anti-M alloimmunization in pregnancy.
Disseminated Endometriosis and Low-Grade Endometrioid Stromal Sarcoma in a Patient with a History of Uterine Morcellation for Adenomyosis
Morcellation of benign uterine tumors allows for removal of the tumors via minimally invasive laparoscopic procedures. However, in rare cases, morcellation has been associated with upstaging of unexpected malignancies. Morcellation has also been associated with dissemination of benign pathologic processes such as endometriosis and leiomyomas. Endometrial stromal sarcoma typically arises in the uterine cavity, although cases of extrauterine endometrioid stromal sarcoma arising out of foci of endometriosis have been reported. Dissemination of endometrial stromal sarcomas can be an unintended consequence of morcellation procedures, as can dissemination of endometriosis, from which endometrioid stromal sarcomas can arise. Herein, we report a case of a 55-year-old woman who was found to have disseminated endometriosis and low-grade endometrioid stromal sarcoma, with bowel and liver parenchymal metastasis, 7 years after undergoing supracervical hysterectomy with unconfined uterine morcellation for adenomyosis. Our case highlights the potential for malignant transformation of disseminated adenomyosis/endometriosis and the importance of patient counseling and shared decision-making prior to morcellation procedures.
Raoultella Bacteremia Presenting as an Acute Self-Limited Illness in an Obstetric Patient
A 20 year-old female at 27-week gestation was admitted for threatened preterm delivery. Following an initially unremarkable hospital course for 12 days, the patient developed fever, chills, generalized malaise, abdominal pain, and diffuse myalgias on day 13 of hospitalization. Raoultella species was isolated from blood cultures on day 16 of hospitalization. The patient’s condition improved within 24 hours of symptom onset, prior to antibiotic initiation, and a premature, viable male infant at 29 weeks and 6 days of gestation was delivered via caesarean section four days later due to breech presentation in the setting of preterm labor. Here, we present the first case of a Raoultella species infection in a gravid female reported in the literature.
Absent Ureteral Efflux after Hysterectomy Leads to Diagnosis of Ureteral Atresia with Renal Atrophy
Iatrogenic injury to the urinary system is a known complication of gynecologic surgery; therefore, intraoperative cystoscopy is frequently performed to assess for such injuries. However, if an abnormality is seen, the differential diagnosis extends beyond iatrogenic causes. A 42-year-old patient underwent a total abdominal hysterectomy and had absent efflux from the right ureteral orifice on cystoscopy. While iatrogenic injury was initially suspected, the intraoperative workup (including intravenous pyelography (IVP)) that ensued led to an empiric diagnosis of right ureteral atresia with ipsilateral renal atrophy that was then confirmed on postoperative imaging. When an abnormality is seen on cystoscopy following gynecologic surgery, it is important to maintain a broad differential diagnosis and to pursue an intraoperative workup with early involvement and close collaboration with urology.