Case Reports in Obstetrics and Gynecology The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Rare Case of Leiomyoma and Adenomyosis in Mayer-Rokitansky-Kuster-Hauser Syndrome Sun, 23 Oct 2016 09:32:08 +0000 We report a case of adenomyosis which developed from a hypoplastic uterus and leiomyoma in a patient with MRKH syndrome. A 45-year-old Malay female with primary amenorrhoea and primary infertility presented with abdominal mass and abdominal pain. She is phenotypically female, has well developed secondary sexual characteristics, and has normal female external genitalia with shallow vagina dimple. Transabdominal ultrasonography showed a homogenous adnexal mass of 10 × 8 cm, uterus sized 5 × 4 cm, and normal kidneys. A complex mass of right adnexa was demonstrated by CT scan. Exploratory laparotomy showed torsion of right adnexal mass and rudimentary uterus with fibroid but no endometrial tissue and blind end with absent cervix. The normal right ovary and tube were not visualized. The left fallopian tube and ovary were normal. It is also complicated by vaginal agenesis. Removal of right adnexal mass and rudimentary uterus was done with preservation of left ovary. The histologic diagnosis was uterine adenomyosis and leiomyoma arising from the right adnexa, possibly from the broad ligament. P. S. Hoo, A. R. Norhaslinda, and J. N. Shah Reza Copyright © 2016 P. S. Hoo et al. All rights reserved. Low-Grade Appendiceal Mucinous Neoplasm Involving the Endometrium and Presenting with Mucinous Vaginal Discharge Sun, 23 Oct 2016 06:57:24 +0000 Primary appendiceal mucinous lesions are uncommon and represent a spectrum from nonneoplastic mucous retention cysts to invasive adenocarcinoma. Low-grade appendiceal mucinous neoplasms (LAMNs) represent an intermediate category on this spectrum and can be classified according to whether or not they are confined to the appendix. Although LAMNs are frequently confined to the appendix, they can also spread to the peritoneum and clinically progress as pseudomyxoma peritonei (i.e., mucinous ascites). Thus, the appropriate classification of appendiceal primary neoplasia is essential for prognosis and influences clinical management. In addition, the precise classification, management, and clinical outcome of patients with disseminated peritoneal disease remain controversial. Here, we report an unusual case of LAMN with pseudomyxoma peritonei that initially presented with mucinous and bloody vaginal discharge. Pathological evaluation revealed low-grade appendiceal mucinous neoplasm with secondary involvement of the peritoneum, ovaries, and endometrial surface. Therefore, LAMN should be considered in the differential diagnosis of mucinous vaginal discharge. Vera Vavinskaya, Joel M. Baumgartner, Albert Ko, Cheryl C. Saenz, and Mark A. Valasek Copyright © 2016 Vera Vavinskaya et al. All rights reserved. Ruptured Ectopic Pregnancy with Contralateral Ovarian Serous Cyst Adenoma Torsion: Laparoscopic Management of Double Trouble Thu, 20 Oct 2016 08:38:14 +0000 Adnexal torsion is responsible for 2.7% of all gynecological emergencies. Ectopic pregnancy is relatively common, occurring in 2% of all pregnancies. We report the second case of ruptured right tubal ectopic gestation with torsion of serous cystadenoma of left ovary. This was diagnosed after emergency laparoscopy done for acute abdomen. Right salpingectomy and left ovarian detorsion followed by cystectomy were done laparoscopically. Deepa Ganesh, Anirudh Rajkumar, J. S. Rajkumar, and Venkatesan Guru Copyright © 2016 Deepa Ganesh et al. All rights reserved. Management of Psoriasis Herpeticum in Pregnancy: A Clinical Conundrum Thu, 20 Oct 2016 06:48:44 +0000 Introduction. Kaposi varicelliform eruption (KVE) is a widespread cutaneous viral infection, most commonly herpes simplex virus, which affects patients with underlying dermatosis. When KVE occurs in a patient with a history of psoriasis, it is referred to as psoriasis herpeticum, a rare subtype of KVE with only a handful of cases reported in the literature. To the authors’ knowledge, we report for the first time a case of psoriasis herpeticum in pregnancy. Case Presentation. A 23-year-old woman in her third pregnancy presented at 26-week gestation with a 10-year history of psoriasis. Cutaneous examination revealed diffuse psoriatic plaques with scattered ~1 cm erosions. Punch biopsy of the skin revealed herpes simplex virus (HSV) infection within a psoriatic plaque, necessitating dermatological treatment. The patient experienced premature rupture of membranes at 37-week gestation. Pelvic exam showed no evidence of herpetic lesions. After labor augmentation, the patient delivered a healthy female infant with no evidence of HSV infection. Discussion. Psoriasis herpeticum is a rare and potentially devastating complication of an underlying dermatosis. With a paucity of data available to guide pregnancy-specific issues, the general management of this condition is controversial and requires a multidisciplinary care approach. Concerns for systemic infection in the mother and vertical transmission to the neonate are of critical importance. Leanne Almario, Albert S. Antonyan, Dennis A. Porto, Hunter Gomez-Roberts, Ali Alhousseini, and Bernard Gonik Copyright © 2016 Leanne Almario et al. All rights reserved. A Pregnancy with Severe Hypertrophic Obstructive Cardiomyopathy after Surgery for an Implantable Cardioverter Defibrillator: A Case Report and Literature Review Tue, 18 Oct 2016 14:26:13 +0000 Hypertrophic obstructive cardiomyopathy (HOCM) is cardiac hypertrophy of ventricular myocardium with left ventricular outflow tract obstruction. We report a pregnancy with HOCM after defibrillator implantation surgery. The patient was a 33-year-old nulligravida and was categorized as New York Heart Association class II. Her brain natriuretic peptide (BNP) level was 724.6 pg/dL at preconception. She received careful pregnancy management. However, because frequent uterine contractions were observed at 25 weeks and 6 days of pregnancy, she was hospitalized, and magnesium sulfate was started as a tocolytic agent. At 27 weeks and 5 days of pregnancy, she had respiratory discomfort and orthopnea with a sudden decrease in peripheral oxygen saturation. Cardiac ultrasonography showed a worsened condition of HOCM and her BNP level was 1418.0 pg/mL. We performed an emergent cesarean section and she delivered a boy weighing 999 g. The Apgar score was 8 and 9 points at 1 and 5 minutes, respectively. The mother’s heart failure quickly improved after birth and she was discharged at 10 days postoperatively. Fluctuations in circulatory dynamics during pregnancy may sometimes exacerbate heart disease. Therefore, the risks should be fully explained and careful assessment of cardiac function should be performed during pregnancy in patients with severe HOCM. Takashi Mitsui, Hisashi Masuyama, Kentaro Ejiri, Kei Hayata, Hiroshi Ito, and Yuji Hiramatsu Copyright © 2016 Takashi Mitsui et al. All rights reserved. How Colposcopy Misses Invasive Cervical Cancer: A Case Report from the IMPROVE-COLPO Study Tue, 18 Oct 2016 14:16:04 +0000 Colposcopy with biopsy is pivotal to cervical cancer prevention programs as it is called to identify the precancerous lesions on patients that screen positive. We present a cervical cancer case from IMPROVE-COLPO, a postmarketing, multicenter, two-arm observational study on US community colposcopy that collects outcomes with the adjunctive Dynamic Spectral Imaging (DSI) in its prospective arm. A 45-year-old woman was seen for suffering of heavy periods. She had cytology of Atypical Squamous Cells of Undetermined Significance (ASC-US) and was Human Papillomavirus (HPV) positive. Her colposcopy did not recognize the underlying condition and opted for no biopsy. The DSI assessment led to a biopsy of a lesion challenging traditional colposcopic templates: small, away from the cervical os, with slow acetowhitening development. Pathology review revealed the presence of invasive squamous carcinoma. In the era of sensitive screening, it is concerning that invasive cancers can challenge colposcopy and that the way to improve colposcopy is to collect multiple biopsies from each patient. The case presented indicates that the adjunctive objective assessment by DSI increases reassurance that observations outside of traditional standard visual templates are not underestimated or ignored. Jeff Livingston and Emmanouil Papagiannakis Copyright © 2016 Jeff Livingston and Emmanouil Papagiannakis. All rights reserved. Leiomyoma of the Vulva: A Diagnostic Challenge Case Report Wed, 12 Oct 2016 13:00:14 +0000 Uterine leiomyomas are common and can affect up to 30% of women older than 35 years. Despite this, leiomyomas of the vulva are rare, masquerading, and usually misdiagnosed as Bartholin cyst preoperatively. These smooth muscle tumors are typically painless, solitary, and well circumscribed and can affect female of any age group. We present a case of a 46-year-old female that presented to the clinic with 2-year history of right labial mass and was diagnosed as Bartholin cyst initially. The patient underwent elective excision under spinal anaesthesia and the mass was removed. The final diagnosis after microscopy result showed benign vulvar leiomyoma. Saad Kurdi, Abdullah S. Arafat, Maysan Almegbel, and Mayson Aladham Copyright © 2016 Saad Kurdi et al. All rights reserved. Fetal Right Ventricular Diverticulum Detected by Prenatal Ultrasound Screening Wed, 12 Oct 2016 09:58:35 +0000 Prenatal ultrasound screening has allowed for the detection of in utero cardiac abnormalities. Specifically, distinction is possible between ventricular diverticula and aneurysms, which is important because each condition has a different clinical outcome. We report the case of a 35-year-old, gravida 1, para 1 woman, with no significant past medical history, who underwent routine prenatal ultrasound screening at 32 weeks’ gestation. A four-chamber ultrasound of the fetal heart combined with M-mode echocardiography showed abnormal dilatation of the right ventricular chamber measuring 2.2 cm × 1.0 cm but with normal contractility. Delivery was performed at full term by cesarean section, and a right ventricular diverticulum was confirmed by postnatal cardiac computed tomography. The baby developed normally with no cardiac sequelae during followup. This case demonstrates the importance of making a correct diagnosis of ventricular diverticula by prenatal ultrasound when abnormal dilatation of the fetal ventricle is identified during routine screening. Because evaluating the wall contractility by M-mode ultrasound leads to evaluating whether it has the myocardium, we conclude that M-mode echocardiography is effective for the purpose of prenatal cardiac diagnosis and can distinguish between ventricular aneurysms and functioning ventricular diverticula. Daisuke Katsura, Kaori Hayashi, Shunichiro Tsuji, Tetsuo Ono, Akiko Ishiko, Kentaro Takahashi, and Takashi Murakami Copyright © 2016 Daisuke Katsura et al. All rights reserved. Comment on “Minilaparotomy Hysterectomy as a Suitable Choice of Hysterectomy for Large Myoma Uteri: Literature Review” Tue, 11 Oct 2016 06:36:10 +0000 Flavia Sorbi, Francesco Magni, and Massimiliano Fambrini Copyright © 2016 Flavia Sorbi et al. All rights reserved. A Case of Type 2 Youssef’s Syndrome following Caesarean Section for Placenta Previa Totalis Mon, 10 Oct 2016 13:51:13 +0000 Vesicouterine fistula is a rare type of urogenital fistulas. It is most commonly observed after cesarean section (C/S) due to iatrogenic reasons. In this article, a case of a vesicouterine fistula which developed after C/S operation is presented. This was the patient’s second C/S and this time placenta previa totalis was the primary pathology. Since it is a rare complication, we found it interesting, and, in this article, this clinical problem was discussed with details about diagnosis and treatment in light of the literature. Sefa Kurt and Funda Obuz Copyright © 2016 Sefa Kurt and Funda Obuz. All rights reserved. A Historic Case of Cardiac Surgery in Pregnancy Mon, 10 Oct 2016 11:35:02 +0000 Background. Heart disease is the leading cause of nonobstetric mortality in pregnant women. Because of high risk, medical management represents the first line of treatment. However, when medical treatment fails, cardiac surgery becomes necessary. Case Presentation. A 27-year-old female who underwent successfully cardiac surgery three times within 3 years. At the first time, she had an aortic valve replacement at 25 weeks of gestation after an infectious endocarditis complicated with an ischemic stroke. At 39 weeks of gestation, she had delivered, vaginally, a healthy baby boy weighing 2800 g. In the second time, pregnant again at 30 weeks of gestation, she had a mitral valve replacement with an aortic prosthesis reinforcement after a paraprosthetic regurgitation and a mitral vegetation. A fetal death in utero had occurred; the extraction of the fetus by cesarean section with a tubal ligation was performed after stabilization of the mother. In the third time, she underwent successfully a mitral prosthesis replacement with Bentall’s procedure after a mitral prosthesis disinsertion with an abscess of aortic annulus due to new episode of infectious endocarditis. Conclusion. Our patient has assembled almost all poor prognosis factors, which makes her a real historic case, probably never described in the literature. Said Benlamkaddem, Adnane Berdai, Smael Labib, and Mustapha Harandou Copyright © 2016 Said Benlamkaddem et al. All rights reserved. Accurate Diagnosis of Severe Hypospadias Using 2D and 3D Ultrasounds Tue, 27 Sep 2016 09:41:15 +0000 The hypospadias is the most common urogenital anomaly of male neonates but the prenatal diagnosis of this is often missed before birth. We present the prenatal diagnosis of a severe penoscrotal hypospadias using 2D and 3D ultrasounds. 3D sonography allowed us the best evaluation of the genitals and their anatomical relations. This ample detailed study allowed us to show the findings to the parents and the pediatric surgeon and to configure the best information about the prognosis and surgical treatment. Vanesa Rodríguez Fernández, Carlos López Ramón y Cajal, Elena Marín Ortiz, and Nerea Sarmiento Carrera Copyright © 2016 Vanesa Rodríguez Fernández et al. All rights reserved. Intracystic Primary Squamous Cell Carcinoma of the Breast: A Challenging Diagnosis Mon, 26 Sep 2016 06:18:19 +0000 We report a case of a 36-year-old woman that presented with a painful mass in the outer quadrants of the left breast that had grown rapidly. Physical examination revealed a well circumscribed elastic mass and breast ultrasound showed a cyst measuring 26 mm with vegetation growing on the inner wall. Microscopic evaluation, after fine needle aspiration cytology (FNAC), suggested benign lesion. Tumorectomy was performed and the final diagnosis was a pure squamous cell carcinoma (SCC) of the breast. A simple mastectomy with sentinel node biopsy was performed. The histological study of the specimen revealed residual SCC and the sentinel lymph node was negative. The patient received 6 cycles of adjuvant chemotherapy and adjuvant radiotherapy. Four years later, the patient is free of disease. Vera Ramos, João Fraga, Teresa Simões, and Margarida Figueiredo Dias Copyright © 2016 Vera Ramos et al. All rights reserved. Chlamydia Peritonitis and Ascites Mimicking Ovarian Cancer Sun, 25 Sep 2016 06:09:51 +0000 Background. Pelvic inflammatory disease (PID) rarely results in diffuse ascites. Severe adhesive disease secondary to PID may lead to the formation of inclusion cysts and even pelvic peritoneal nodularity due to postinflammatory scarring and cause an elevation of serum CA-125 levels. The constellation of these findings may mimic an ovarian neoplasm. Case. We report a case of a 22-year-old female who presented with multiple pelvic cysts and diffuse ascites due to Chlamydia trachomatis infection. The initial gynecologic exam did not reveal obvious evidence of PID; however, a positive Chlamydia trachomatis test, pathologic findings, and the exclusion of other etiologies facilitated the diagnosis. Conclusion. Chlamydia trachomatis and other infectious agents should be considered in the differential diagnosis of a young sexually active female with abdominal pain, ascites, and pelvic cystic masses. Thorough workup in such a population may reduce the number of more invasive procedures as well as unnecessary repeat surgical procedures. Anar Gojayev, Diana P. English, Matthew Macer, and Masoud Azodi Copyright © 2016 Anar Gojayev et al. All rights reserved. Umbilical Nodule with Cyclical Bleeding: A Case Report and Literature Review of Atypical Endometriosis Thu, 22 Sep 2016 13:47:32 +0000 Endometriosis is defined as the presence of endometrial glands and stroma outside the uterus. It affects 3 to 10 percent of women of reproductive age. Umbilical endometriosis is rare, with an estimated incidence of 0.5–1.0% among all cases of endometriosis, and is usually secondary to prior laparoscopic surgery involving the umbilicus. In this report, we described a case of umbilical endometriosis treated with surgical resection and highlight the great importance of medical history compared to complementary diagnostic tests that can be sometimes inconclusive. Marlene Teixeira Andrade, Cláudia V. Marques de Freitas, Sara Filipa Camacho Câmara, and José Joaquim Nunes Vieira Copyright © 2016 Marlene Teixeira Andrade et al. All rights reserved. Corrigendum to “Extensive Thrombosis of the Inferior Vena Cava and Left Renal Vein in a Neonate” Mon, 19 Sep 2016 09:22:39 +0000 Moez Kdous, Oussama Khlifi, Marwene Brahem, Mohamed Khrouf, Sarah Amari, Monia Ferchiou, and Fethi Zhioua Copyright © 2016 Moez Kdous et al. All rights reserved. Reversible Fetal Renal Impairment following Angiotensin Receptor Blocking Treatment during Third Trimester of Pregnancy: Case Report and Review of the Literature Thu, 08 Sep 2016 07:52:04 +0000 Background. Late pregnancy usage of angiotensin converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARB) may cause severe oligohydramnios due to fetal renal impairment. Affected neonates will often suffer from fatal, renal, and respiratory failure. Case. A 39-year-old multigravida admitted due to anhydramnios secondary to valsartan (ARB) exposure at 30 weeks’ gestation. Following secession of treatment amniotic fluid volume returned to normal. Delivery was induced at 34 weeks’ gestation following premature rupture of membranes and maternal fever. During the two-year follow-up, no signs of renal insufficiency were noted. Conclusions. This description of reversible fetal renal damage due to ARB intake during pregnancy is the first to show no adverse renal function in a two-year follow-up period. This case may help clinicians counsel patients with pregnancies complicated by exposure to these drugs. Tal Saar, Lorinne Levitt, and Hagai Amsalem Copyright © 2016 Tal Saar et al. All rights reserved. Florid Cystic Endosalpingiosis (Müllerianosis) in Pregnancy Wed, 07 Sep 2016 14:30:46 +0000 Cystic endosalpingiosis refers to the existence of heterotopic cystic müllerian tissue resembling structures of the fallopian tubes. We report a case of florid cystic endosalpingiosis discovered in a pregnant woman during a scheduled cesarean section and review the current knowledge of this disease. A 30-year-old woman with a twin pregnancy attended the hospital day unit at term. The first twin was in a breech presentation and a cesarean section was scheduled. During the procedure the uterine fundus and part of the body were seen completely seeded with multitude of cyst-like structures resembling hydatids of Morgagni. The immunohistochemistry analysis showed a positive expression for PAX8 (Box-8), CK7, and estrogen and progesterone receptors. The lesions did not disappear after pregnancy. Cystic endosalpingiosis should be always borne in mind, even in pregnancy, when it comes to making the differential diagnosis of a pelvic or systemic multicystic mass. José Morales-Roselló, Loida Pamplona-Bueno, Beatriz Montero-Balaguer, Domingo Desantes-Real, and Alfredo Perales-Marín Copyright © 2016 José Morales-Roselló et al. All rights reserved. Complex Laparoscopic Myomectomy with Severe Adhesions Performed with Proper Preventive Measures and Power Morcellation Provides a Safe Choice in Certain Infertility Cases Wed, 07 Sep 2016 10:09:39 +0000 Laparoscopic myomectomy offers a real benefit to infertile patients with uterine fibroids and peritoneal adhesions. The procedure requires a skilled surgeon and laparoscopy technique to minimize adhesion formation and other proven benefits. Restrictions arise since this procedure requires power morcellation for fibroid tissue extraction. Two years ago, the Food and Drug Administration in the United States of America (FDA) issued the alert on power morcellation for uterine leiomyomas, addressing the risk of malignant cell spreading within the abdominal cavity (actual risk assessment from 1 in 360 to 1 in 7400 cases). We review a 30-year-old female, without previous gestations, hypermenorrhea, intermenstrual bleeding, and chronic pelvic pain. Transvaginal ultrasound reports multiple fibroids in the right portion of a bicornuate uterus. Relevant history includes open myomectomy 6 years before and a complicated appendectomy, developing peritonitis within a year. Laparoscopy revealed multiple adhesions blocking uterine access, a bicornuate uterus, and myomas in the expected site. Myomectomy was performed utilizing power morcellation with good results. FDA recommendations have diminished this procedure’s selection, converting many to open variants. This particular case was technically challenging, requiring morcellation, and safety device deployment was impossible, yet the infertility issue was properly addressed. Patient evaluation, safety measures, and laparoscopy benefits may outweigh the risks in particular cases as this one. Jaime Alfaro-Alfaro, María de los Ángeles Flores-Manzur, Roberto Nevarez-Bernal, and Rodrigo Ayala-Yáñez Copyright © 2016 Jaime Alfaro-Alfaro et al. All rights reserved. Apocrine Adenocarcinoma of the Vulva: A Case Report and Review of the Literature Wed, 07 Sep 2016 08:53:19 +0000 Primary vulvar adenocarcinomas are very rare. We describe the rare case of primary vulvar apocrine adenocarcinoma, a histologically rare subtype of vulvar adenocarcinoma. A 57-year-old Japanese woman presented with an enlarging vulvar mass. A dark-red, hemorrhagic, ulcerated tumor was on the right side of the anterior labial commissure measuring approximately  cm. Preoperative biopsy showed poorly differentiated carcinoma with partial differentiation to adenocarcinoma. Systemic examination revealed lymph node metastases in both inguinal regions and no other primary source. We performed radical vulvectomy and bilateral inguinal and pelvic lymphadenectomy. Histopathologic diagnosis was apocrine adenocarcinoma of the vulva with inguinal lymph node metastases, pT1bN2bM0. Surgical margins were negative. The patient received no adjuvant chemotherapy or radiation. Inguinal lymph node recurrence occurred after six months. Reresection and adjuvant tomotherapy were performed. After a further 12 months of observation, no rerecurrence was observed. The patient is now on follow-up. Kohei Aoyama, Hiroshi Matsushima, Morio Sawada, Taisuke Mori, Satoru Yasukawa, and Jo Kitawaki Copyright © 2016 Kohei Aoyama et al. All rights reserved. Successful Treatment of Uterine Arteriovenous Malformation due to Uterine Trauma Tue, 06 Sep 2016 15:52:41 +0000 Uterine arteriovenous malformation (AVM) is defined as abnormal and nonfunctional connections between the uterine arteries and veins. Although the patients typically present with vaginal bleeding, some patients may experience life-threatening massive bleeding in some circumstances. The treatment of choice depends on the symptoms, age, desire for future fertility, and localization and size of the lesion; however, embolization of the uterine artery is the first choice in symptomatic AVM in patients at reproductive age with expectations of future fertility. We report a case of acquired AVM (after D/C) with an extensive lesion, which was successfully treated with bilateral uterine artery embolization (UAE). Burak Karadag, Onur Erol, Ozgur Ozdemir, Aysel Uysal, Ahmet Sukru Alparslan, Cemil Gurses, and Mert Koroglu Copyright © 2016 Burak Karadag et al. All rights reserved. Luteoma of Pregnancy Presenting with Severe Maternal Virilisation: A Case Report Wed, 31 Aug 2016 13:11:38 +0000 Luteoma of pregnancy is a rare, benign condition characterized by a tumor-like mass of the ovary that emerges during pregnancy and regresses spontaneously after delivery. It is usually asymptomatic and the diagnosis is generally incidental. Luteoma arises from the proliferation of luteinised cell under the influence of β-hCG and can be hormonally active, with production of androgens resulting in maternal and fetal hirsutism and virilisation. We report a case of a 25-year-old primigravida who presented at 28 weeks of gestation with virilisation symptoms. Serum androgen levels were seven-hundred-fold higher than normal. A diagnosis of pregnancy luteoma was made at the time of caesarean section. The ovarian mass, serum androgen levels, and the condition of the patient improved after delivery. Vincenzo Rapisarda, Francesco Pedalino, Veronica Concetta Santonocito, Giorgia Cavalli, and Giuseppe Zarbo Copyright © 2016 Vincenzo Rapisarda et al. All rights reserved. Papillary Squamotransitional Cell Carcinoma of the Uterine Cervix: A Case Report and Review of the Literature Tue, 30 Aug 2016 10:22:57 +0000 Introduction. Papillary squamotransitional cell carcinoma (PSTCC) is an uncommon histopathological variant of squamous cell carcinoma (SCC) of the uterine cervix, which occurs in postmenopausal women. Presentation of Case. Herein, we describe a case of a 63-year-old woman who presented with 4-month history of postmenopausal vaginal bleeding. Vaginal examination revealed a fragile lesion of size  cm invading left posterior vaginal fornice and parametrium. Biopsy showed the presence of papillae containing fibrovascular cores lined by multilayered atypical epithelial cells resembling squamous and transitional cell epithelium, confirming the diagnosis of PSTCC of the uterine cervix. After staging work-up she was staged according to the International Federation of Gynecology and Obstetrics (FIGO) staging system 2009 as FIGO IIB, and she was started on extended field concurrent chemoradiation. Discussion. PSTCC of the uterine cervix is an extremely rare and aggressive entity. PSTCC is often characterized by the presence of papillary structures with prominent fibrovascular cores. PSTCC of the uterine cervix should be differentiated from transitional cell carcinoma, squamous papilloma, papillary adenocarcinoma, and cervical intraepithelial neoplasia with papillary features. Conclusion. PSTCC of the uterine cervix is a diagnostic challenge; further studies regarding the mechanism underlying the development of PSCC are warranted. Shomaila Aamir M. Akbar, Mutahir A. Tunio, Sadeq Al-Dandan, Kareema Mohammed Y. Salamah, and Mushabbab AlAsiri Copyright © 2016 Shomaila Aamir M. Akbar et al. All rights reserved. Vaginal Hysterectomy with Anterior Four-Arm Mesh Implant Technique in the Surgical Treatment of a Woman with Total Pelvic Organ Prolapse and Urinary Incontinence: A Case Report and Review of the Literature Mon, 29 Aug 2016 06:18:54 +0000 Purpose. We present a case report of a woman with total POP and SUI who was treated with a technique utilizing vaginal hysterectomy followed by the placement of a four-arm synthetic polypropylene mesh implant system. Methods. An 81-year-old grand-multiparous woman presented to our clinic complaining of a vaginally protruding mass and urinary incontinence. A surgical approach including vaginal hysterectomy, anterior four-arm mesh implant, posterior large segment vaginal enterocele repair, and perineoplasty with levator ani fixation was planned. Results. The patient was discharged home at the second postoperative day. Follow-up visits at the first, 3rd, and 6th months were normal. There was complete symptomatic relief and objective cure of the POP and urinary incontinence symptoms. Conclusion. We believe that anterior four-arm mesh implant and large posterior repair should be considered after vaginal hysterectomy. Future studies are needed to evaluate the utility of this technique for treatment of POP. Gökmen Sukgen, Esra Saygılı Yılmaz, and Eralp Başer Copyright © 2016 Gökmen Sukgen et al. All rights reserved. Ectopic Molar Pregnancy: Diagnostic Efficacy of Magnetic Resonance Imaging and Review of the Literature Thu, 25 Aug 2016 17:06:42 +0000 Ectopic molar pregnancy is extremely rare, and preoperative diagnosis is difficult. Our literature search found only one report of molar pregnancy diagnosed preoperatively. Moreover, there is no English literature depicting magnetic resonance image (MRI) findings of ectopic molar pregnancy. We report a case of ectopic molar pregnancy preoperatively diagnosed using MRI. A literature review of 31 cases of ectopic molar pregnancy demonstrated that lesions have been found in the fallopian tube (19 cases, 61%), ovary (5 cases, 16%), cornu (3 cases, 10%), peritoneum (2 cases, 6%), uterine cervix (1 case, 3%), and cesarean scar (1 case, 3%). Abdominal pain and abnormal vaginal bleeding were reported in 70% and 61% of the patients, respectively. Twenty-one cases (67%) presented with rupture and hemoperitoneum. All patients underwent surgical resection or dilatation and curettage. Methotrexate therapy was performed in one case because residual trophoblastic tissue was suspected. A second operation was performed in one case of ovarian molar pregnancy because serum hCG levels increased again after primary focal ovarian resection. No patients developed metastatic disease or relapsed. These findings suggest the prognosis of ectopic molar pregnancy to be favorable. Yasushi Yamada, Satoshi Ohira, Teruyuki Yamazaki, and Tanri Shiozawa Copyright © 2016 Yasushi Yamada et al. All rights reserved. Novel Hypomorphic Mutation in FANCD2 Gene Observed in a Fetus with Multiple Congenital Anomalies Tue, 23 Aug 2016 13:27:54 +0000 Congenital anomalies affect 1% to 2% of the newborns. The urinary tract and the kidneys are involved in 4-5% of the cases while upper-extremities abnormalities are present in 10%. Certain anomalies occur in isolation, whereas others are associated with systemic conditions. The prenatal detection of fetal anomalies compatible with life is a challenge for both the parents and the physician. The prognosis for the fetus/newborn and the reproductive decisions of the family largely depend on the causes underlying the disease. The reported case is of a G2P1 pregnant woman referred for routine ultrasound scan at 24 weeks of gestation (w.g.). The fetus had growth retardation, right kidney agenesis, bilateral absence of radial bones and thumbs, radial deviation of the wrists, and short humeri. Nuchal fold thickness was 5 mm and there was a single umbilical artery. After termination of pregnancy, SNP array genotyping and next-generation sequencing of targeted candidate-genes were performed trying to clarify the etiology of the fetal polymalformative syndrome. A new hypomorphic mutation in FANCD2 gene was found to underlie this fetal anomaly. The case illustrates that patients/families affected by rare monogenic disorders may benefit from application of modern technologies like microarrays and NGS. Radoslava Vazharova, Svetlana Vragaleva, Violeta Dimitrova, Samuil Ivanov, Lubomir Balabanski, Maxim Malinov, and Draga Toncheva Copyright © 2016 Radoslava Vazharova et al. All rights reserved. Medical and Surgical Management of Postpartum Hemorrhage in a Woman with Factor XIII Deficiency Thu, 18 Aug 2016 16:32:52 +0000 Factor XIII deficiency is a rare inherited coagulopathy. Factor XIII is the last clotting factor in the coagulation cascade to insure strength and stability to fibrin clots. Without this enzyme, the fibrous clot is unstable and nonresistant to fibrinolysis. Gravid women with this congenital disease are especially at risk for complications including miscarriages and hemorrhage without appropriate interventions. We present a case of a woman in her 20s with Factor XIII deficiency who was treated with cryoprecipitate and had a successful normal spontaneous vaginal delivery; subsequently, patient suffered from postpartum hemorrhage and consumptive coagulopathy due to consumption of Factor XIII, requiring emergency surgical intervention. Intraoperative management was challenged by an ethical dilemma involving the patient’s religious beliefs about not receiving blood. This paper will discuss the mechanism of Factor XIII and the medical and surgical management involved with this patient. Michael Cheng, Janelle Nassim, Ario Angha, Krisna Srey, Alexander Canales, Chauniqua Kiffin, Yessin Ashmawy, and Andrew A. Rosenthal Copyright © 2016 Michael Cheng et al. All rights reserved. Sister Mary Joseph Nodule as a First Manifestation of a Metastatic Ovarian Cancer Thu, 18 Aug 2016 09:49:59 +0000 A 76-year-old female presented to our hospital with a 2 cm firm, nontender, protuberant umbilical nodule. She received treatment with antibiotics for suspected granuloma, with no improvement after two months. High levels of CA125 as well as an ovarian cyst and intrathoracic and intra-abdominal lesions on imaging studies made us suspect an ovarian cancer with a Sister Mary Joseph nodule (SMJN) and other metastases. A bilateral salpingo-oophorectomy and umbilical and omentum tumor resections were performed and a metastatic ovarian serous adenocarcinoma was diagnosed by histopathology. After surgery, the patient received chemotherapy with paclitaxel, carboplatin, and bevacizumab; however paclitaxel allergy was observed. As a result, chemotherapy continued with carboplatin and bevacizumab every three weeks for a total of 6 courses. Currently, she is still undergoing treatment with bevacizumab and CA125 levels have been progressively decreasing. SMJN is a rare umbilical metastasis which needs to be considered as a differential diagnosis in the presence of an umbilical tumor for prompt treatment initiation. Giannina Calongos, Mai Ogino, Takatoshi Kinuta, Masateru Hori, and Tatsuo Mori Copyright © 2016 Giannina Calongos et al. All rights reserved. Extreme Elevation of Alkaline Phosphatase in a Pregnancy Complicated by Gestational Diabetes and Infant with Neonatal Alloimmune Thrombocytopenia Wed, 17 Aug 2016 08:53:11 +0000 There have been few case reports of isolated elevation of alkaline phosphatase beyond the normal physiologic amount with subsequent return to baseline after delivery. Here we present a similar case of extreme elevation of alkaline phosphatase in a pregnancy complicated by gestational diabetes and subsequently by neonatal alloimmune thrombocytopenia (NAIT). Svjetlana Lozo, Amir Atabeygi, and Michael Healey Copyright © 2016 Svjetlana Lozo et al. All rights reserved. Bleeding versus Clotting: A Complex Case of a Large Fibroid Uterus Causing Menorrhagia and a DVT Sun, 14 Aug 2016 14:28:15 +0000 A 43-year-old woman presented with severe anaemia secondary to menorrhagia. Pelvic ultrasound showed a large intramural posterior fundal fibroid. Hysteroscopy showed the fibroid distorting the endometrial cavity, precluding Mirena® device insertion. As she was initially hesitant to have a hysterectomy, medical management with the oral contraceptive pill (OCP) and tranexamic acid was instituted, with good effect. Months later, after a long road trip, she presented with left leg swelling, and a Doppler ultrasound confirmed an extensive deep vein thrombosis (DVT). She was commenced on warfarin for anticoagulation but presented again with menorrhagia precipitated by overanticoagulation. After initial stabilization with multiple blood transfusions and reversal of anticoagulation, the warfarin was ceased in favour of enoxaparin and she underwent inferior vena cava (IVC) filter insertion prior to a total abdominal hysterectomy. Mass effect from large uterine fibroids can cause venous thromboembolism (VTE). A duplex ultrasound of the lower limbs if a woman presents with a large fibroid could identify asymptomatic DVTs in such women. A prehysterectomy IVC filter would then reduce their risk of postoperative pulmonary embolism. Medical management of menorrhagia with procoagulants should be avoided for management of menorrhagia in such women given their higher risk of developing VTE. Sangeeta Ramanan, Jude Chapman-Wardy, and Roy Watson Copyright © 2016 Sangeeta Ramanan et al. All rights reserved.