- Email: [email protected]
Conservative surgical management of cesarean scar pregnancy with vasopressin
154 Hence, in comparison to the other routes, misoprostol administered sublingually is effective and safe for labor induction (Table 1).
References
BRIEF COMMUNICATIONS [2] Elhassan EM, Mirghani OA, Adam I. Intravaginal misoprostol versus dinoprostone as cervical ripening and labor-inducing agents. Int J Gynecol Obstet 2004;85:285—6. [3] Feitosa FE, Sampaio ZS, Alencar Jr CA, Amorim MM, Passini Jr R. Sublingual vs. vaginal misoprostol for induction of labor. Int J Gynecol Obstet 2006;94:91—5.
[1] Elhassan EM, Mirghani OA, Adam I. Misoprostol vs. oxytocin for induction of labor. Int J Gynecol Obstet 2005;91:254—5.
Conservative surgical management of cesarean scar pregnancy with vasopressin Ming-Jie Yang ⁎, Jen-Yu Tseng, Wei-Lun Hsu Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, National Yang-Ming University School of Medicine, Taipei, Taiwan Received 30 December 2006; received in revised form 7 February 2007; accepted 8 February 2007
KEYWORDS Cesarean section; Scar pregnancy; Vasopressin
The incidence of scar pregnancies is rising with the rate of cesarean sections. A pregnancy within a cesarean scar can produce a healthy, normally developing fetus. For this reason, even though a scar pregnancy is abnormally implanted, it should not be confused with an ectopic or a cervical pregnancy [1]. Although scar pregnancies can have favorable outcomes, the richly vascularized conceptive tissue within the scar may cause catastrophic hemorrhage. When this happens, immediate action is necessary to decrease the risk of life-threatening complications. Medical options to stop abnormal bleeding – such as local compression with an inflated Foley balloon; cervical cerclage before curettage; local injection of potassium chloride, prostaglandins, or methotrexate to cause abortion; and the systemic use of methotrexate, actinomycin D, or etoposide – have been described. Total or subtotal hysterectomy can be required to control the bleeding caused by a pregnancy within a cesarean section scar. However, transarterial embolization (TAE) of both uterine arteries ⁎ Corresponding author. Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, 201, Shih-Pai Rd., Sec. 2, Taipei 112, Taiwan. Tel.: +886 2 2875 7566; fax: +886 2 2873 4101. E-mail address: [email protected] (M.-J. Yang). doi:10.1016/j.ijgo.2007.02.007
plus excision of the conceptive tissues has been performed early in the pregnancy to preserve the uterus and future fertility. The outcome of this double procedure has been considered satisfactory, with low morbidity, acceptable blood loss, and short hospital stay [2]. Bilateral TAE of the uterine arteries has been widely used for the reduction of uterine myomas or for adenomyosis, postabortal or postpartum hemorrhage, and intractable bleeding after cesarean hysterectomy. Nevertheless, necrosis of the buttocks, uterus, and labiae has been reported as a complication of TAE, along with intrauterine infection. An alternative method to decrease intraoperative blood loss and prevent such complications seems to deserve greater attention. An intramural injection of diluted vasopressin significantly reduces blood loss during uterine myomectomy, and has long been used with satisfying results and few complications [3]. Compared with the costs of TAE and its possible complications, using vasopressin intramurally for hemostasis during the evacuation of abnormally implanted conceptive tissue is inexpensive. Injecting diluted vasopressin around the cesarean scar before tissue excision can be performed easily with minimal blood loss, hence achieving the same effects as TAE more economically and with fewer complications. This method offers physicians another option when they are faced with a scar pregnancy requiring surgical intervention. Conservative surgical excision with a local injection of vasopressin have the following advantages over TAE: (1) it allows for the complete evacuation of abnormally implanted gestational tissue while preserving the uterus and fertility; (2) it is associated with less morbidity; (3) it requires a shorter hospital stay; and (4) it is more cost-effective.
BRIEF COMMUNICATIONS
References [1] Herman A, Weinraub Z, Avrech O, Maymon R, Ron-El R, Bukovsky Y. Follow up and outcome of isthmic pregnancy located in a previous cesarean section scar. Br J Obstet Gynaecol 1995;102: 839—41. [2] Yang MJ, Jeng MH. Combination of transarterial embolization of uterine arteries and conservative surgical treatment for preg-
155 nancy in a cesarean section scar: a report of 3 cases. J Reprod Med 2003;48:213—6. [3] Ginsburg ES, Gleason RE, Benson CB, Freidman AJ, Garfield JM. The effect of operative technique and uterine size on blood loss during myomectomy: a prospective randomized study. Fertil Steril 1993;60(6):956—62.
Spontaneous monozygotic monochorionic twin pregnancy in non-mosaic Turner's syndrome S.A. El-Shawarby ⁎, C.V. Steer Department of Obstetrics and Gynecology, Princess Royal University Hospital, Orpington, Kent, UK Received 20 November 2006; received in revised form 25 January 2007; accepted 31 January 2007
KEYWORDS Pregnancy; karyotype; Turner's syndrome
A 36-year-old patient was referred to the gynecology unit with a history of primary infertility for 2 years. She had regular cycles, and there was no gynecologic or medical history of note. Her partner's semen analysis was normal. Baseline investigations showed fluctuating FSH levels (3.8–26 mIU/mL), low midluteal progesterone and normal prolactin. Thyroid function assessment revealed Hashimoto's thyroiditis, for which thyroxine was initiated. Ultrasound revealed normal uterus, normal ovaries with good follicular activity, and bilateral patent tubes on hysterosalpingography. In view of her autoimmune thyroiditis, patient's karyotype was checked and revealed 45XO Turner's syndrome (TS). Echocardiography was normal. After careful consideration, arrangements for oocyte donation were initiated. In the interterm, the patient returned with a viable twin pregnancy at 6 weeks gestation following spontaneous conception. She is currently 24 weeks pregnant, and undergoing appropriate antenatal care. Fertility in patients with TS is a rare phenomenon as most suffer from gonadal dysgenesis, and only 2% of pregnancies are a result of spontaneous ovulation. Moreover, these pregnancies are associated with high rates of miscarriage, stillbirth, and chromosomal aberration [1]. This case appears to be the first report of a spontaneous monozygotic monochorionic twin pregnancy in a patient with ⁎ Corresponding author. Tel.: +44 1689 863000; fax: +44 1689 864040. E-mail address: [email protected] (S.A. El-Shawarby). doi:10.1016/j.ijgo.2007.01.013
apparently non-mosaic (monozomic) TS. Careful history taking and high index of clinical suspicion led to the diagnosis of Hashimoto's thyroiditis and TS, considering the patient's family history of thyroid disorders and the fact that between 10 and 30% of individuals with TS develop primary hypothyroidism that is generally associated with anti-thyroid antibodies [1]. Other investigators have described the first spontaneous singleton pregnancy in a patient with known non-mosaic TS. They carefully looked for a cryptic second cell line with a normal karyotype to exclude low-grade mosaicism as much as possible by karyotyping white blood cells, skin and ovarian fibroblasts [2], although it is recognized that this can never be totally excluded and that a peripheral blood karyotype is usually adequate [1]. In the case described, the diagnosis of non-mosaic TS was made by karyotyping of white blood cells only. Indeed, several authors have accepted that the “pure” 45, X karyotype, can in rare cases be compatible with normal fertility. It was thus suggested that if ovarian failure in those patients does not evolve too fast, some might be fertile early in their reproductive life [3]. Therefore, those who have spontaneous menstrual cycles should be counseled about not postponing pregnancies [1].
References [1] Saenger P, Wikland KA, Conway GS, Davenport M, Gravholt CH, Hintz R, et al. Recommendations for the diagnosis and management of Turner Syndrome. J Clin Endocrinol Metab 2001;86:3061—9. [2] Cools M, Rooman RPA, Wauters J, Jacqemyn Y, Du Caju MVL. A nonmosaic 45, X karyotype in a mother with Turner's syndrome and in her daughter. Fertil Steril 2004;82:923—5. [3] Hreinsson JG, Otala M, Fridstrom M, Borgstrom B, Rasmussen C, Lundqvist M, et al. Follicles are found in the ovaries of adolescent girls with Turner's syndrome. J Clin Endocrinol Metab 2002;87:3618—23.
References
BRIEF COMMUNICATIONS [2] Elhassan EM, Mirghani OA, Adam I. Intravaginal misoprostol versus dinoprostone as cervical ripening and labor-inducing agents. Int J Gynecol Obstet 2004;85:285—6. [3] Feitosa FE, Sampaio ZS, Alencar Jr CA, Amorim MM, Passini Jr R. Sublingual vs. vaginal misoprostol for induction of labor. Int J Gynecol Obstet 2006;94:91—5.
[1] Elhassan EM, Mirghani OA, Adam I. Misoprostol vs. oxytocin for induction of labor. Int J Gynecol Obstet 2005;91:254—5.
Conservative surgical management of cesarean scar pregnancy with vasopressin Ming-Jie Yang ⁎, Jen-Yu Tseng, Wei-Lun Hsu Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, National Yang-Ming University School of Medicine, Taipei, Taiwan Received 30 December 2006; received in revised form 7 February 2007; accepted 8 February 2007
KEYWORDS Cesarean section; Scar pregnancy; Vasopressin
The incidence of scar pregnancies is rising with the rate of cesarean sections. A pregnancy within a cesarean scar can produce a healthy, normally developing fetus. For this reason, even though a scar pregnancy is abnormally implanted, it should not be confused with an ectopic or a cervical pregnancy [1]. Although scar pregnancies can have favorable outcomes, the richly vascularized conceptive tissue within the scar may cause catastrophic hemorrhage. When this happens, immediate action is necessary to decrease the risk of life-threatening complications. Medical options to stop abnormal bleeding – such as local compression with an inflated Foley balloon; cervical cerclage before curettage; local injection of potassium chloride, prostaglandins, or methotrexate to cause abortion; and the systemic use of methotrexate, actinomycin D, or etoposide – have been described. Total or subtotal hysterectomy can be required to control the bleeding caused by a pregnancy within a cesarean section scar. However, transarterial embolization (TAE) of both uterine arteries ⁎ Corresponding author. Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, 201, Shih-Pai Rd., Sec. 2, Taipei 112, Taiwan. Tel.: +886 2 2875 7566; fax: +886 2 2873 4101. E-mail address: [email protected] (M.-J. Yang). doi:10.1016/j.ijgo.2007.02.007
plus excision of the conceptive tissues has been performed early in the pregnancy to preserve the uterus and future fertility. The outcome of this double procedure has been considered satisfactory, with low morbidity, acceptable blood loss, and short hospital stay [2]. Bilateral TAE of the uterine arteries has been widely used for the reduction of uterine myomas or for adenomyosis, postabortal or postpartum hemorrhage, and intractable bleeding after cesarean hysterectomy. Nevertheless, necrosis of the buttocks, uterus, and labiae has been reported as a complication of TAE, along with intrauterine infection. An alternative method to decrease intraoperative blood loss and prevent such complications seems to deserve greater attention. An intramural injection of diluted vasopressin significantly reduces blood loss during uterine myomectomy, and has long been used with satisfying results and few complications [3]. Compared with the costs of TAE and its possible complications, using vasopressin intramurally for hemostasis during the evacuation of abnormally implanted conceptive tissue is inexpensive. Injecting diluted vasopressin around the cesarean scar before tissue excision can be performed easily with minimal blood loss, hence achieving the same effects as TAE more economically and with fewer complications. This method offers physicians another option when they are faced with a scar pregnancy requiring surgical intervention. Conservative surgical excision with a local injection of vasopressin have the following advantages over TAE: (1) it allows for the complete evacuation of abnormally implanted gestational tissue while preserving the uterus and fertility; (2) it is associated with less morbidity; (3) it requires a shorter hospital stay; and (4) it is more cost-effective.
BRIEF COMMUNICATIONS
References [1] Herman A, Weinraub Z, Avrech O, Maymon R, Ron-El R, Bukovsky Y. Follow up and outcome of isthmic pregnancy located in a previous cesarean section scar. Br J Obstet Gynaecol 1995;102: 839—41. [2] Yang MJ, Jeng MH. Combination of transarterial embolization of uterine arteries and conservative surgical treatment for preg-
155 nancy in a cesarean section scar: a report of 3 cases. J Reprod Med 2003;48:213—6. [3] Ginsburg ES, Gleason RE, Benson CB, Freidman AJ, Garfield JM. The effect of operative technique and uterine size on blood loss during myomectomy: a prospective randomized study. Fertil Steril 1993;60(6):956—62.
Spontaneous monozygotic monochorionic twin pregnancy in non-mosaic Turner's syndrome S.A. El-Shawarby ⁎, C.V. Steer Department of Obstetrics and Gynecology, Princess Royal University Hospital, Orpington, Kent, UK Received 20 November 2006; received in revised form 25 January 2007; accepted 31 January 2007
KEYWORDS Pregnancy; karyotype; Turner's syndrome
A 36-year-old patient was referred to the gynecology unit with a history of primary infertility for 2 years. She had regular cycles, and there was no gynecologic or medical history of note. Her partner's semen analysis was normal. Baseline investigations showed fluctuating FSH levels (3.8–26 mIU/mL), low midluteal progesterone and normal prolactin. Thyroid function assessment revealed Hashimoto's thyroiditis, for which thyroxine was initiated. Ultrasound revealed normal uterus, normal ovaries with good follicular activity, and bilateral patent tubes on hysterosalpingography. In view of her autoimmune thyroiditis, patient's karyotype was checked and revealed 45XO Turner's syndrome (TS). Echocardiography was normal. After careful consideration, arrangements for oocyte donation were initiated. In the interterm, the patient returned with a viable twin pregnancy at 6 weeks gestation following spontaneous conception. She is currently 24 weeks pregnant, and undergoing appropriate antenatal care. Fertility in patients with TS is a rare phenomenon as most suffer from gonadal dysgenesis, and only 2% of pregnancies are a result of spontaneous ovulation. Moreover, these pregnancies are associated with high rates of miscarriage, stillbirth, and chromosomal aberration [1]. This case appears to be the first report of a spontaneous monozygotic monochorionic twin pregnancy in a patient with ⁎ Corresponding author. Tel.: +44 1689 863000; fax: +44 1689 864040. E-mail address: [email protected] (S.A. El-Shawarby). doi:10.1016/j.ijgo.2007.01.013
apparently non-mosaic (monozomic) TS. Careful history taking and high index of clinical suspicion led to the diagnosis of Hashimoto's thyroiditis and TS, considering the patient's family history of thyroid disorders and the fact that between 10 and 30% of individuals with TS develop primary hypothyroidism that is generally associated with anti-thyroid antibodies [1]. Other investigators have described the first spontaneous singleton pregnancy in a patient with known non-mosaic TS. They carefully looked for a cryptic second cell line with a normal karyotype to exclude low-grade mosaicism as much as possible by karyotyping white blood cells, skin and ovarian fibroblasts [2], although it is recognized that this can never be totally excluded and that a peripheral blood karyotype is usually adequate [1]. In the case described, the diagnosis of non-mosaic TS was made by karyotyping of white blood cells only. Indeed, several authors have accepted that the “pure” 45, X karyotype, can in rare cases be compatible with normal fertility. It was thus suggested that if ovarian failure in those patients does not evolve too fast, some might be fertile early in their reproductive life [3]. Therefore, those who have spontaneous menstrual cycles should be counseled about not postponing pregnancies [1].
References [1] Saenger P, Wikland KA, Conway GS, Davenport M, Gravholt CH, Hintz R, et al. Recommendations for the diagnosis and management of Turner Syndrome. J Clin Endocrinol Metab 2001;86:3061—9. [2] Cools M, Rooman RPA, Wauters J, Jacqemyn Y, Du Caju MVL. A nonmosaic 45, X karyotype in a mother with Turner's syndrome and in her daughter. Fertil Steril 2004;82:923—5. [3] Hreinsson JG, Otala M, Fridstrom M, Borgstrom B, Rasmussen C, Lundqvist M, et al. Follicles are found in the ovaries of adolescent girls with Turner's syndrome. J Clin Endocrinol Metab 2002;87:3618—23.