Case Reports in Obstetrics and Gynecology The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . 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. Intraperitoneal Hemorrhage in a Pregnant Woman with Hyperemesis Gravidarum: Vitamin K Deficiency as a Possible Cause Thu, 11 Aug 2016 11:54:52 +0000 Hyperemesis gravidarum can cause various vitamin deficiencies. Vitamin K deficiency can lead to coagulopathy or hemorrhagic diathesis. A nulliparous Japanese woman with hyperemesis gravidarum at 105/7 weeks was admitted with giant myoma, intestinal obstruction, and abdominal pain. Treatment for a degenerative myoma was instituted with intravenous antibiotics. The abdominal pain ameliorated, but intestinal obstruction persisted. At 166/7 weeks, we performed laparotomy for release of intestinal obstruction, when intraabdominal bleeding of 110 mL existed. Blood tests revealed coagulopathy secondary to vitamin K deficiency. The coagulopathy responded to intravenous vitamin K injection. Coagulopathy due to vitamin K deficiency can occur with hyperemesis gravidarum, and coexisting intestinal obstruction and broad-spectrum antibiotics can aggravate the deficiency. Yosuke Baba, Hiroyuki Morisawa, Koyomi Saito, Hironori Takahashi, Kazuma Rifu, and Shigeki Matsubara Copyright © 2016 Yosuke Baba et al. All rights reserved. Two Cases of Endometrial Cancer in Twin Sisters with Myotonic Dystrophy Tue, 09 Aug 2016 12:54:55 +0000 We describe two cases of endometrial cancer (EC) occurring in nulligravid twin sisters with myotonic dystrophy. Both tested negative for Lynch syndrome and both were treated with laparoscopic hysterectomy with bilateral salpingooophorectomy and adjuvant radiotherapy. Although EC tends to run in families, the diagnosis in itself is not considered sufficient cause for screening or prophylactic measures in close relatives. However, the presence of additional risk factors, such as nulligravidity and myotonic dystrophy in the underlying cases, may call for extra vigilance in first-degree family members. Ezra Y. Koh and Paul J. M. van Kesteren Copyright © 2016 Ezra Y. Koh and Paul J. M. van Kesteren. All rights reserved. Urethral Solitary Fibrous Tumor: A Rare Pathologic Diagnosis of a Periurethral Mass Mon, 08 Aug 2016 13:30:43 +0000 Solitary fibrous tumors (SFTs) may occur at any site in the body. SFTs can only be conclusively diagnosed based on histopathologic and immunohistochemical characteristics of the tumor. The presence of SFTs in the abdomen and pelvis is extremely rare. To our knowledge no cases of urethral solitary fibrous tumor in the literature have been reported so far. We present a case of a solitary fibrous tumor arising from the urethra in a twenty-three-year-old female presenting with vaginal mass. Gaby N. Moawad, Elias D. Abi Khalil, Cheryl Silverbrook, Stephanie Barak, Alice Semerjian, and Michael Phillips Copyright © 2016 Gaby N. Moawad et al. All rights reserved. A Case of the TOF with APV Complicated with Polyhydramnios and Severe Bronchomalacia Sun, 07 Aug 2016 14:32:00 +0000 Absent pulmonary valve syndrome (APVS) is a rare congenital heart disease with severe pulmonary insufficiency, characterized with aneurysmal dilation in the pulmonary artery and one or both of its branches. We presented a rare case with APVS and literature review in this letter. Prenatal USG examination of the fetus at the 26th week of gestation revealed severe polyhydramnios, dilatation at right ventricle, and abnormal appearance of the heart. At the 31st gestational week, the baby was born with cesarean section. The newborn had right heart failure but had no hydrops fetalis. Therefore, severe respiratory distress observed in the infant has been associated with pulmonary complications. The infant, who had respiratory acidosis according to blood gas analysis, was intubated and attached to mechanical ventilator. Despite progressively increased respiratory support and other interventions, the infant died on the 3rd day of admission. Compression against bronchial tree and esophagus due to dilated pulmonary artery and its branches may inevitably lead to bronchomalacia and polyhydramnios. In conclusion, presence of polyhydramnios and the possibility of severe bronchomalacia should be kept in mind; and due to the risk of early neonatal mortality, delivery should be performed in a center where pediatric heart surgery is available. Ali Seven, Emine Esin Yalinbas, and Rahmi Ozdemir Copyright © 2016 Ali Seven et al. All rights reserved. A Case of Vaginal Stillbirth in the Presence of Placenta Previa at 33 Weeks of Gestation Sun, 07 Aug 2016 08:31:55 +0000 It was demonstrated that second- and third-trimester therapeutic termination of pregnancy (TOP) is feasible in cases with placenta previa. We report a 34-year-old woman with complex fetal malformations associated with placenta previa. An ultrasound examination at 21 weeks of gestation revealed fetal growth restriction (FGR) and complex fetal malformations associated with a placenta previa. After extensive information, the parents opted for careful observation. Thereafter, FGR gradually progressed and we observed arrest of end-diastolic velocity of the umbilical artery. Finally, intrauterine fetal death (IUFD) was confirmed at 33 weeks of gestation. Two days after IUFD, the patient experienced labor pain. The placenta and dead fetus weighing 961 g were vaginally delivered, and total bleeding was 270 mL. Although further studies to confirm the dynamic change of the uteroplacental blood flow are necessary to avoid the risk of maternal hemorrhage, vaginal TOP with placenta previa after feticide or IUFD would be feasible. Yukiko Chinen, Tadatsugu Kinjo, Hayase Nitta, Yui Kinjo, Hitoshi Masamoto, and Yoichi Aoki Copyright © 2016 Yukiko Chinen et al. All rights reserved. Prenatal Diagnosis of Isolated Agnathia-Otocephaly: A Case Report and Review of the Literature Thu, 04 Aug 2016 14:09:05 +0000 Agnathia is a rare disease characterized by the absence of a mandible. Few cases of prenatally diagnosed isolated agnathia have been reported. We present a case report and review of the literature of prenatally diagnosed agnathia. A 38-year-old woman (gravida 0, para 0) was referred to our hospital at 28 weeks and 3 days of gestation for fetal evaluation because of polyhydramnios and suspected facial anomalies. Three-dimensional ultrasonography and MRI indicated agnathia. Premature rupture of the membranes occurred before the parents could reach a decision on the postnatal treatment. We performed emergency cesarean section on the second day of the 33rd week of gestation. The neonate was deemed nonresuscitable and he died of airway obstruction shortly after birth. Because agnathia is associated with very poor prognosis, accurate prenatal diagnosis and detailed counseling should be promptly provided before unexpected delivery to the parents for the determination of postnatal treatment. Kazuhiro Kajiwara, Tomohiro Tanemoto, Chie Nagata, and Aikou Okamoto Copyright © 2016 Kazuhiro Kajiwara et al. 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.