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Cytological detection of trophoblasts for rapid diagnosis of pregnancy of unknown location
BRIEF COMMUNICATIONS
vaginal tape obturator (TVT-O) sling procedure without problems and voiding function was not further studied. Thirteen months after the sling operation the patient was brought to hospital hemodynamically unstable and with extreme abdominal pain. The abdominal cavity was fluid-filled and emergency laparoscopy revealed both blood and urine. A 1.5-cm bladder rupture was sutured laparoscopically. After the operation residual urine was less than 25 mL. No further visits were arranged. Six months later the patient was admitted again with abdominal pain. Ultrasound revealed a hypotonic bladder with 800 mL of residual urine. As before, fluid was seen in the abdominal cavity. CT scan revealed a small bladder rupture, which was confirmed by cystoscopy. The rupture was treated conservatively by urinary catheterization for 2 weeks. Since that time, hypotonic bladder has been treated with intermittent catheterization.
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In the present case, urinary retention resulted in erosion of the tape material into the bladder. This report of repetitive spontaneous urinary bladder rupture in a patient with surgically treated cauda equina syndrome and vaginal tape to correct presumptive stress urinary incontinence suggests that vaginal tape should be used cautiously, if at all, in a patient with altered perineal sensation. Conflict of interest The authors have no conflicts of interest to declare. References [1] Cass AS. Diagnostic studies in bladder rupture. Indications and techniques. Urol Clin North Am 1989;16(2):267–73.
0020-7292/$ – see front matter © 2011 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. doi:10.1016/j.ijgo.2011.12.003
Cytological detection of trophoblasts for rapid diagnosis of pregnancy of unknown location Masato Kinugasa ⁎, Tetsuya Sato, Maki Tamura Department of Obstetrics and Gynecology, Amagasaki Iryou-Seikyou Hospital, Amagasaki, Japan
a r t i c l e
i n f o
Article history: Received 30 July 2011 Received in revised form 4 November 2011 Accepted 6 December 2011 Keywords: Cytodiagnosis Ectopic pregnancy Spontaneous abortion Trophoblasts
Diagnostic uterine curettage and pathological examination of the specimen can be used when a pregnancy's location is unknown. However, it may take a few days to confirm the histopathological diagnosis, and frozen section examination sometimes leads to false-negative results due to a limited specimen [1]. The aim of the present study was to evaluate the utility of cytodiagnosis of uterine specimens to differentiate between ectopic pregnancy and spontaneous abortion. Between January 1, 2000, and April 30, 2011, 22 women who had been diagnosed with a pregnancy of unknown location and were of stable physical status were examined. Normal gestation had been excluded, but a definitive diagnosis could not be made by ultrasound or quantitative human chorionic gonadotropin (hCG) test. The patients provided informed consent and the study received approval from the hospital's ethical review board. Uterine specimens were prepared by direct imprinting of suctioned or curetted uterine contents onto glass slides in 18 patients,
⁎ Corresponding author at: 12-16-1 Minami-Mukonosou, Amagasaki, Hyogo Prefecture, Japan 661–0033. Tel.: +81 06 6436 1701; fax: +81 06 6437 9153. E-mail address: [email protected] (M. Kinugasa).
while in 4 patients the samples were collected from the endometrium using cell samplers. All samples were stained with Papanicolaou stain and the cytological findings were confirmed within 1–2 hours on the same day they had been collected. The specimens were judged positive, suggestive of spontaneous abortion, if 1 or more syncytiotrophoblasts were detected (Fig. 1). The uterine specimens were also sent for histologic examination for confirmation of the diagnosis. Seven specimens were judged to be positive cytologically and in all cases the final diagnosis was spontaneous abortion. In 5 cases the histological diagnosis confirmed spontaneous abortion, while in 2 cases no chorionic villi were found histologically despite positive cytology; however, spontaneous abortion was confirmed by a promptly declining hCG value after curettage. Fifteen specimens were judged to be negative for chorionic villi both cytologically and histologically. Of these, 3 were diagnosed as complete spontaneous abortion, while 12 were finally diagnosed as ectopic pregnancy. Seven of these 12 patients had elective surgery and 5 were treated successfully with methotrexate (MTX). None of the patients had complications of significant intraperitoneal bleeding from a ruptured ectopic pregnancy. Previous reports on the use of cytodiagnosis in cases of pregnancy of unknown location concluded that the diagnostic procedure was helpful in differentiating between ectopic pregnancy and spontaneous abortion [2,3]. Although false-positives cannot be excluded because trophoblasts may migrate from ectopic implantation sites into the uterine cavity, such cases are considered uncommon. Early differentiation of pregnancy of unknown location has become more important because it facilitates successful MTX therapy for ectopic pregnancy and reduces unnecessary MTX therapy for spontaneous abortion. Cytological detection of trophoblasts is a rapid, low-cost, and reliable diagnostic tool to evaluate patients in whom the location of pregnancy is unknown.
88
BRIEF COMMUNICATIONS
Fig. 1. Syncytiotrophoblasts (STs) in the specimens of suctioned uterine contents: (a) STs with a large cell cluster. Tadpole-like multinucleated large cells are characteristic of STs; (b,c) Scattered small STs (Papanicolaou stain × 200).
Conflict of interest The authors have no conflicts of interest to declare.
[2] Jacobson ES, Goetsch M. Cytologic identification of trophoblastic epithelium in products of first-trimester abortion. Obstet Gynecol 1985;66(1): 124–6. [3] Strengell L, Ammala M. Rapid diagnosis of intrauterine pregnancy by smear cytology. Acta Cytol 1997;41(3):942–4.
References [1] Barak S, Oettinger M, Perri A, Cohen HI, Barenboym R, Ophir E. Frozen section examination of endometrial curettings in the diagnosis of ectopic pregnancy. Acta Obstet Gynecol Scand 2005;84(1):43–7.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.11.004
Acute fatty liver of pregnancy over a 10-year period at a Tunisian tertiary care center Monia Malek Mellouli a,⁎, Fethi Ben Amara a, Hayen Maghrebi b, Mourad Bouchnack b, Néji Khaled c, Hédi Reziga a a b c
Gynecology and Obstetrics Department “B”, Gynecology Obstetrics and Neonatology Center, La Rabta Hospital, Tunis, Tunisia Department of Anesthesia and Reanimation, Gynecology Obstetrics and Neonatology Center, La Rabta Hospital, Tunis, Tunisia Emergency Department, Gynecology Obstetrics and Neonatology Center, La Rabta Hospital, Tunis, Tunisia
a r t i c l e
i n f o
Article history: Received 4 May 2011 Received in revised form 6 November 2011 Accepted 20 December 2011 Keywords: Acute fatty liver of pregnancy Disseminated intravascular coagulation Pre-eclampsia Third trimester
⁎ Corresponding author at: Limp mail n° 110, 2011 Denden, Tunisia. Tel.: + 216 98 455959; fax: + 216 71 572711. E-mail address: [email protected] (M.M. Mellouli).
Acute fatty liver of pregnancy (AFLP) is a rare life-threatening disease that occurs in the third trimester or early postpartum period. Its incidence ranges from 1 in 7000 to 1 in 20 000 pregnancies [1]. Early detection of AFLP combined with identification of milder cases, rapid termination of pregnancy, and advances in critical care have all helped improve the prognosis. The aim of the present study was to determine the clinical profile, laboratory findings, and maternal and neonatal outcomes in patients with AFLP, and to suggest an active therapeutic approach. A retrospective study was conducted of patients with AFLP who were treated in the tertiary care center of La Rabta Hospital in Tunis, Tunisia, between January 2000 and December 2009. The study was approved by the hospital's institutional review board. Patients included in the study were those with histologically confirmed AFLP or those with clinical symptoms, laboratory values, ultrasound findings, and a course highly suggestive of the disease. Exclusion criteria were other causes of liver disorder in pregnancy, such as HELLP syndrome, viral hepatitis, intrahepatic cholestasis of
vaginal tape obturator (TVT-O) sling procedure without problems and voiding function was not further studied. Thirteen months after the sling operation the patient was brought to hospital hemodynamically unstable and with extreme abdominal pain. The abdominal cavity was fluid-filled and emergency laparoscopy revealed both blood and urine. A 1.5-cm bladder rupture was sutured laparoscopically. After the operation residual urine was less than 25 mL. No further visits were arranged. Six months later the patient was admitted again with abdominal pain. Ultrasound revealed a hypotonic bladder with 800 mL of residual urine. As before, fluid was seen in the abdominal cavity. CT scan revealed a small bladder rupture, which was confirmed by cystoscopy. The rupture was treated conservatively by urinary catheterization for 2 weeks. Since that time, hypotonic bladder has been treated with intermittent catheterization.
87
In the present case, urinary retention resulted in erosion of the tape material into the bladder. This report of repetitive spontaneous urinary bladder rupture in a patient with surgically treated cauda equina syndrome and vaginal tape to correct presumptive stress urinary incontinence suggests that vaginal tape should be used cautiously, if at all, in a patient with altered perineal sensation. Conflict of interest The authors have no conflicts of interest to declare. References [1] Cass AS. Diagnostic studies in bladder rupture. Indications and techniques. Urol Clin North Am 1989;16(2):267–73.
0020-7292/$ – see front matter © 2011 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. doi:10.1016/j.ijgo.2011.12.003
Cytological detection of trophoblasts for rapid diagnosis of pregnancy of unknown location Masato Kinugasa ⁎, Tetsuya Sato, Maki Tamura Department of Obstetrics and Gynecology, Amagasaki Iryou-Seikyou Hospital, Amagasaki, Japan
a r t i c l e
i n f o
Article history: Received 30 July 2011 Received in revised form 4 November 2011 Accepted 6 December 2011 Keywords: Cytodiagnosis Ectopic pregnancy Spontaneous abortion Trophoblasts
Diagnostic uterine curettage and pathological examination of the specimen can be used when a pregnancy's location is unknown. However, it may take a few days to confirm the histopathological diagnosis, and frozen section examination sometimes leads to false-negative results due to a limited specimen [1]. The aim of the present study was to evaluate the utility of cytodiagnosis of uterine specimens to differentiate between ectopic pregnancy and spontaneous abortion. Between January 1, 2000, and April 30, 2011, 22 women who had been diagnosed with a pregnancy of unknown location and were of stable physical status were examined. Normal gestation had been excluded, but a definitive diagnosis could not be made by ultrasound or quantitative human chorionic gonadotropin (hCG) test. The patients provided informed consent and the study received approval from the hospital's ethical review board. Uterine specimens were prepared by direct imprinting of suctioned or curetted uterine contents onto glass slides in 18 patients,
⁎ Corresponding author at: 12-16-1 Minami-Mukonosou, Amagasaki, Hyogo Prefecture, Japan 661–0033. Tel.: +81 06 6436 1701; fax: +81 06 6437 9153. E-mail address: [email protected] (M. Kinugasa).
while in 4 patients the samples were collected from the endometrium using cell samplers. All samples were stained with Papanicolaou stain and the cytological findings were confirmed within 1–2 hours on the same day they had been collected. The specimens were judged positive, suggestive of spontaneous abortion, if 1 or more syncytiotrophoblasts were detected (Fig. 1). The uterine specimens were also sent for histologic examination for confirmation of the diagnosis. Seven specimens were judged to be positive cytologically and in all cases the final diagnosis was spontaneous abortion. In 5 cases the histological diagnosis confirmed spontaneous abortion, while in 2 cases no chorionic villi were found histologically despite positive cytology; however, spontaneous abortion was confirmed by a promptly declining hCG value after curettage. Fifteen specimens were judged to be negative for chorionic villi both cytologically and histologically. Of these, 3 were diagnosed as complete spontaneous abortion, while 12 were finally diagnosed as ectopic pregnancy. Seven of these 12 patients had elective surgery and 5 were treated successfully with methotrexate (MTX). None of the patients had complications of significant intraperitoneal bleeding from a ruptured ectopic pregnancy. Previous reports on the use of cytodiagnosis in cases of pregnancy of unknown location concluded that the diagnostic procedure was helpful in differentiating between ectopic pregnancy and spontaneous abortion [2,3]. Although false-positives cannot be excluded because trophoblasts may migrate from ectopic implantation sites into the uterine cavity, such cases are considered uncommon. Early differentiation of pregnancy of unknown location has become more important because it facilitates successful MTX therapy for ectopic pregnancy and reduces unnecessary MTX therapy for spontaneous abortion. Cytological detection of trophoblasts is a rapid, low-cost, and reliable diagnostic tool to evaluate patients in whom the location of pregnancy is unknown.
88
BRIEF COMMUNICATIONS
Fig. 1. Syncytiotrophoblasts (STs) in the specimens of suctioned uterine contents: (a) STs with a large cell cluster. Tadpole-like multinucleated large cells are characteristic of STs; (b,c) Scattered small STs (Papanicolaou stain × 200).
Conflict of interest The authors have no conflicts of interest to declare.
[2] Jacobson ES, Goetsch M. Cytologic identification of trophoblastic epithelium in products of first-trimester abortion. Obstet Gynecol 1985;66(1): 124–6. [3] Strengell L, Ammala M. Rapid diagnosis of intrauterine pregnancy by smear cytology. Acta Cytol 1997;41(3):942–4.
References [1] Barak S, Oettinger M, Perri A, Cohen HI, Barenboym R, Ophir E. Frozen section examination of endometrial curettings in the diagnosis of ectopic pregnancy. Acta Obstet Gynecol Scand 2005;84(1):43–7.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.11.004
Acute fatty liver of pregnancy over a 10-year period at a Tunisian tertiary care center Monia Malek Mellouli a,⁎, Fethi Ben Amara a, Hayen Maghrebi b, Mourad Bouchnack b, Néji Khaled c, Hédi Reziga a a b c
Gynecology and Obstetrics Department “B”, Gynecology Obstetrics and Neonatology Center, La Rabta Hospital, Tunis, Tunisia Department of Anesthesia and Reanimation, Gynecology Obstetrics and Neonatology Center, La Rabta Hospital, Tunis, Tunisia Emergency Department, Gynecology Obstetrics and Neonatology Center, La Rabta Hospital, Tunis, Tunisia
a r t i c l e
i n f o
Article history: Received 4 May 2011 Received in revised form 6 November 2011 Accepted 20 December 2011 Keywords: Acute fatty liver of pregnancy Disseminated intravascular coagulation Pre-eclampsia Third trimester
⁎ Corresponding author at: Limp mail n° 110, 2011 Denden, Tunisia. Tel.: + 216 98 455959; fax: + 216 71 572711. E-mail address: [email protected] (M.M. Mellouli).
Acute fatty liver of pregnancy (AFLP) is a rare life-threatening disease that occurs in the third trimester or early postpartum period. Its incidence ranges from 1 in 7000 to 1 in 20 000 pregnancies [1]. Early detection of AFLP combined with identification of milder cases, rapid termination of pregnancy, and advances in critical care have all helped improve the prognosis. The aim of the present study was to determine the clinical profile, laboratory findings, and maternal and neonatal outcomes in patients with AFLP, and to suggest an active therapeutic approach. A retrospective study was conducted of patients with AFLP who were treated in the tertiary care center of La Rabta Hospital in Tunis, Tunisia, between January 2000 and December 2009. The study was approved by the hospital's institutional review board. Patients included in the study were those with histologically confirmed AFLP or those with clinical symptoms, laboratory values, ultrasound findings, and a course highly suggestive of the disease. Exclusion criteria were other causes of liver disorder in pregnancy, such as HELLP syndrome, viral hepatitis, intrahepatic cholestasis of