Volume 5, Issue 1

Abnormal placentation is a significant source of maternal morbidity and mortality with increasing incidence due to rising rates of cesarean delivery. While traditionally managed with cesarean-hysterectomy, other management strategies are available. We report a case of a G4P2 woman with two prior cesarean deliveries, who presented at 21 weeks and was diagnosed with an extensive placenta percreta. She expressed a desire for pregnancy termination. Given extensive intra-abdominal placental invasion, intrauterine fetal demise was induced with fetal intracardiac potassium chloride, systemic methotrexate was administered, and the pregnancy was managed conservatively with the demised fetus in situ . Resolution of placental tissue occurred over 4 months. Chorioamnionitis developed at the equivalent of 41 weeks’ gestational age, and she underwent a successful gravid hysterectomy. Antepartum management with induced fetal demise and delayed hysterectomy can be considered in extreme cases of previable invasive placenta percreta.

We present a case of a spontaneous reposition of an incarcerated uterus in the third trimester. The uterus is retroverted in approximately 15% of pregnancies during the first trimester. The uterus raises and the fundus usually enters the abdominal cavity by the 14 th week. Diagnosis and treatment of posterior incarceration with sacculation of the anterior uterine wall remain a challenge for the obstetrician. If the diagnosis is missed, there is a high risk of damaging the bladder and the cervix during a caesarean section, as the surgeon might not be aware of the disturbed anatomical situation. Treatment of a persistent retroverted uterus and outcome of intervention depend mainly on time of diagnosis as well as the presence of symptoms and other associated risk factors. A 36-year-old primigravida with known uterine posterior incarceration since 22 weeks and 5 days, confirmed by ultrasound scan and magnetic resonance imaging (MRI), presented at the 31 st week with correct uterine polarity. To our knowledge, there is only one well-documented case in the literature with spontaneous reposition of an incarcerated uterus after the 28 th week of pregnancy.

Objective: Placental mesenchymal dysplasia (PMD) is a rare vascular anomaly characterized by mesenchymal stem villous hyperplasia. Accurate differential diagnosis of PMD is crucial to predict fetal outcomes associated with serious obstetrical complications. Methods: We reviewed the clinical and pathological features and immunohistochemical and imaging findings of three patients with PMD. Results: First trimester sonographic cystic findings identified molar pregnancy or PMD. However, PMD was highly suspected according to the maternal serum human chorionic gonadotropin (hCG) titers, fetal karyotypes, and imaging findings. The outcome of patient 1, in whom placental multicystic areas decreased as pregnancy progressed, was a live birth. In contrast, the babies of patients 2 and 3 were stillborn, and multicystic formations detected during the first trimester completely and consistently occupied the placentas. Pathological and immunohistochemical analyses using anti-CD34 and anti-D2-40 antibodies distinguished the cisternae from multiple small vessels in the villi. Immunohistochemical analyses using anti-CK7 and anti-Ki-67 antibodies did not detect excessive proliferation of trophoblasts. Most abnormal villi associated with PMD comprised stromal cells that did not react with an anti-p57 kip2 antibody. Conclusion: In patients with PMD, if the percentage of the normal placental area decreases as pregnancy progresses, the possibility of fetal growth restriction and intrauterine fetal demise should always be considered. The immunostaining pattern of CD34 and D2-40 may represent a unique feature of PMD and can provide supporting evidence for the differential diagnosis of PMD.

Placental invasion anomalies are divided into three according to invasion of uterine wall as placenta accreta, increta and percreta. In placenta percreta, the most severe but the least common form, the placenta invades the full thickness of the uterine wall and also it can attach to adjacent organs in the abdomen like the bladder and rectum. It is a potentially life treating condition. There is no recommended management strategy for placenta percreta. We herein report two cases managed differently and discuss the management options in the light of the literature.

The use of intra-aortic balloon occlusion (IABO) could be effective in achieving the quick control of bleeding in emergency settings and in supporting the provision of safe radical treatment through resuscitative endovascular balloon occlusion of the aorta (REBOA). We herein report our experience of a patient with life-threatening postpartum hemorrhage after cesarean section who was successfully treated by hysterectomy with IABO without fluoroscopy. We believe that this procedure is very useful and safe, and that it should be considered as one of methods for controlling bleeding in patients with life-threatening postpartum hemorrhage.

We report a case of successful external cephalic version after preterm premature rupture of membranes. Transcervical amnioinfusion was used to facilitate the procedure due to minimal amniotic fluid, and the patient subsequently delivered vaginally. A femoral fracture was later identified in the neonate.

Despite the fact that spontaneous (non-traumatic) bilateral humeral fractures without trauma are seen as a rare entity, especially grand mal epileptic convulsions may result in these types of fracture in the adult. A 32-year-old early postpartum patient without osteoporosis and with a history of epilepsy is presented here. She had not used anticonvulsant drugs for nearly ten years. After a convulsive epileptic attack on the day of a cesarean section, bilateral humeral shaft fractures were diagnosed on the 5 th postpartum day causing bilateral shoulder pain. An earlier chest anteroposterior X-ray including the humerus would be a help in order to perform earlier diagnosis. It should be taken into consideration that humeral bone fractures may happen without any trauma especially in early postpartum patients. A high degree of suspicion should be kept in mind while treating a patient in the post-ictal phase; as, if treated promptly, treatment leads to complete functional recovery.

A 37-year-old primigravida female with placenta previa totalis was transferred to our hospital at 29 weeks of gestation. A transvaginal ultrasound examination showed a dropped placenta into the uterine cervix and an effaced lower uterine segment. The boundary between the cervical muscle layer and the placenta was unclear. Consequently, although it was unclear whether complication of the adherence of placenta was present or not, massive hemorrhage with atonic bleeding in the lower uterine segment after placenta removal was strongly suspected. As the patient had uncontrolled vaginal bleeding, an emergency cesarean section was performed in a hybrid operating room. A transverse fundal incision of the uterus was made, and a 1143 g healthy neonate was delivered. As no signs of placental detachment or persistent bleeding were found, the uterus was closed, leaving the placenta. Thereafter bilateral uterine arterial embolization (UAE) with absorbable gelatin sponges was performed. On the third day after the operation, a second operation for placental removal. The placenta detached smoothly, but compression sutures were placed to control the bleeding at the site of placental removal around the uterine isthmus. In this case, we were able to conduct the treatment smoothly because of the antenatal ultrasound assessment and precise preparation of the cesarean section with UAE in the hybrid operation room. Using the hybrid operation room, sharing detailed surgical planning in cooperation with the physicians from other departments is important for obtaining a good outcome.

Introduction: Massive perivillous fibrinoid deposition (MPFD) is a very rare placental condition characterized by abnormally extensive fibrinoid deposition in the placental villous parenchyma. The aim of this study is to document clinical and pathological features with special focus on pregnancy outcomes of this condition in consecutive cases of MPFD in our local population. Methods: This is a retrospective clinico-pathological study of cases affected by MPFD over the period January 2010–July 2014 in our hospital. We document clinical features (including perinatal outcome and subsequent pregnancies) and placental pathological characteristics. Results: Twelve cases of MPFD were identified among 3640 placentas (0.33%). There was no identified recurrence. The affected infants had adverse outcomes, including intrauterine growth restriction (IUGR) (75%), preterm birth (58.3%), and fetal loss (25%). A high frequency of reduced PAPP-A in the first trimester (25%), and concurrent gestational hypertension or pre-eclampsia (25%) was noted. Conclusion: MPFD is associated with adverse perinatal outcomes. Further research to better understand its pathogenesis and to improve clinical diagnosis and management is warranted.

Vein of Galen aneurysmal malformation (VGAM) is a rare congenital vascular malformation of the central nervous system. Although recent advances in the endovascular treatment and management of neonatal heart failure have resulted in reduced mortality and morbidity, the long-term neurodevelopmental prognosis is not well described. We encounterred a case of prenatally diagnosed VGAM, which was successfully treated, resulting in a favorable neurodevelopmental outcome. In this case, although an emergency intravascular operation was performed due to the post-delivery exacerbation of heart failure, the aneurysmal volume evaluated by magnetic resonance imaging just before the operation was not increased as compared with the prenatal value assessed by ultrasonography. This suggests that the stability of the VGAM volume even under exacerbation of heart failure is a potential parameter to predict the long-term neurodevelopmental prognosis.

We present the case of a 34-year-old woman with a prenatally diagnosed osteogenesis imperfecta type II of one fetus of a diamniotic-dichorionic twin pregnancy at 28 weeks and 2 days of gestation. The diagnosis was suspected after a routine ultrasound examination, specified by 3D-ultrasound and confirmed with moleculargenetic analyses of COL1A1 with DNA of fetal cells obtained after amniotic drainage. Since a premature rupture of membranes occurred a cesarean section was performed at 36 weeks of gestation. Both newborns received primary medical care by neonatologists. The affected child received further treatment initially stationary, later as an ambulant patient. Even though ultrasound is a powerful tool to identify clinical features of osteogenesis imperfecta, the condition can finally only be confirmed by collagen or DNA analyses. We discuss the possibilities and limits of prenatal diagnosis, treatment options as well as issues that are relevant for genetic counseling.

Aim: The Dandy-Walker malformation is a rare abnormality of the central nervous system pertaining to the group of cystic malformations. The frequency of occurrence of the malformation ranges from 1:800 to 35,000 live births. The aim of this study is to investigate the Dandy-Walker malformation in two cases – one by autopsy after abortion due to medical indications during the 25 th gestational week at The Clinic of Embryo and Fetopathology, Center for Maternity and Neonatology, Tunis, Tunisia, and another case of a 1-year-old infant diagnosed with an acute internal hydrocephalus at The Clinic of Neurosurgery, Medical University Plovdiv, Bulgaria, and to compare the results with those in the literature. Results: Both cases are of an isolated Dandy-Walker malformation without any associated abnormalities of the central nervous system and other organs and systems. After the placement of a ventriculoperitoneal shunt in the second case, the child’s condition was greatly improved. Conclusion: The question arises whether the prenatal diagnosis of an isolated Dandy-Walker malformation is an indication for pregnancy termination, and who and after what examinations has the right to make this decision, given the favorable outcome after surgical treatment.

A case of holoprosencephaly (HPE) with proboscis, fused eyes in one orbit, and cyclopia was diagnosed by fetal ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Ultrasonographic examination at 28 weeks of gestation showed fusion of the frontal part of the brain and ventricular dilation. Subsequent CT and MRI examinations confirmed this anomaly as alobar HPE. Amniocentesis followed by chromosome analysis demonstrated karyotype as de novo 45,XY, der (18;21)(q10;q10), with deletion of a short arm of chromosome 18. The pregnancy ended in a premature delivery of a male neonate weighing 1716 g at 34 weeks. Macroscopically, there were mid-frontal proboscis and single orbit with two eyes without normal nasal structures. He died 1 h after birth.

We report the postnatal diagnosis of Van der Woude syndrome (VWS) in a foetus found to have an isolated right cleft lip and palate by ultrasound examination. After prenatal genetic counselling, the parents declined further evaluation by amniocentesis. At delivery, the infant was also found to have labial pits in the lower lip in addition to the cleft lip and palate identified by ultrasound consistent with VWS. Although VWS is rare, its autosomal dominant inheritance and variable penetrance should prompt additional modalities to more thoroughly evaluate the extent of other organ system and more extensive craniofacial anomalies.

Atelosteogenesis type 2 also known as atelosteogenesis de la Chapelle type, De la Chapelle dysplasia, McAlister dysplasia or neonatal osseous dysplasia 1 is an extremely lethal osteochondrodysplasia with unknown incidence. Very few cases have been reported in the literature. We present a case with findings of prenatal ultrasound, autopsy and cytogenetic work up with report of a novel familial mutation.

Background: Twin reversed arterial perfusion (TRAP) sequence is the most severe form of twin to twin transfusion syndrome. Survival of the pump twin is threatened by extreme prematurity from polyhydramnios and cardiac failure, necessitating interventions. Rarely, interventions are indicated as a result of maternal life-threatening complications. The management of an acardiac-myelacephalus variant of TRAP sequence, complicated by severe maternal respiratory distress from tense polyhydramnios is presented in this report. Case presentation: A 29-year-old G3P2, Alive2 was referred to the Perinatal Unit on account of ultrasound diagnosed twin gestation with demise of one twin at an estimated gestational age (EGA) of 29 weeks. She was in severe respiratory distress with central cyanosis, and grossly distended abdomen. Ultrasonography revealed twin gestation with cardiac activity in only one twin and polyhydramnios. The second twin had no recognizable human body structure and retrograde umbilical arterial flow. TRAP sequence with tense polyhydramnios was diagnosed. The respiratory distress was relieved with serial reductive amniocentesis, and she was managed conservatively until an EGA of 34 weeks, when she delivered a live twin that weighed 2.05 kg, and an amorphous twin with a rudimentary limb that weighed 1.82 kg following spontaneous rupture of membranes. Monochorionic placentation was confirmed at delivery. The pump twin was discharged in a satisfactory state after a period of observation. Conclusion: TRAP sequence may be easily misdiagnosed due to its rarity, with adverse consequences. Accurate diagnosis of the condition, and the provision of basic facilities for in utero interventions when indicated are necessary for fetal salvage.

Introduction: Spinal cord injury of the newborn is a rare and critical condition which is typically reported after difficult deliveries. The few cases of spinal cord injury after caesarean section reported in literature are usually associated with intrauterine hyperextension of the head. However, in exceptional cases the authors described intrauterine vascular insults as a possible cause for spinal cord lesions during pregnancy. Presentation of the case: A term infant was born after an uncomplicated caesarean section following cephalic presentation. Pregnancy was reported as uneventful. Foetal ultrasounds were normal and showed no evidence of hyperextension of the head. Although the boy was in good general conditions after birth, he showed a flaccid paralysis of both upper extremities with absent deep tendon reflexes and missing pain response. Other neurologic findings like general tonus and reactivity as well as spontaneous movements of both lower extremities were adequate. A spinal MRI performed at 48 h of life showed intact brachial plexuses with evidence of spinal cord lesion compatible with an ischemic injury. Accurate anamnesis revealed that the mother had perceived reduced foetal movements in the last 2 days before birth, suggesting a possible intrauterine origin of the ischaemic event. Conclusion: Our case reinforces the hypothesis that small ischaemic spinal cord lesions may occur during uncomplicated pregnancy. Therefore, such lesions may not always be related to a difficult delivery. Irrespective of the cause, treatment and parental counselling remain challenging due to the rarity of reported cases.

Fungal neonatal infection with Candida is rare, despite a prevalence of vaginal mycosis of up to 30% during pregnancy. Although there are no recommendations to treat asymptomatic vaginal colonization with candida in healthy pregnant women, this case report highlights that asymptomatic colonization with Candida can lead to chorioamnionitis and systemic neonatal infection with leukemoid reaction. Treatment of asymptomatic candida colonization in women at risk of preterm delivery should be considered.