Volume 5, Issue 2

Bakri balloon implementations for the conservative management of postpartum hemorrhage (PPH) have become more popular in the recent years. The procedure may be regarded as simple, however, it can become a challenging method considering an excessive bleeding patient where there is a race against time. In our daily practice we do not usually use the lithotomy position except for few conditions such as placenta previa, where the lithotomy position is necessary to apply a Bakri balloon during PPH during a cesarean section. Here we would like to present a woman with uterine atony and fundal placenta accreta bleeding, managed with the Bakri balloon without switching to the lithotomy position for the first time in the literature. The bleeding was evaluated successfully with this new method, however, a cesarean hysterectomy was necessary to achieve hemostasis despite the addition of a bilateral uterine artery ligation at the end. The decision to add a vessel ligation to the inflated Bakri balloon should be assessed carefully as uterine artery ligation may be time consuming due to effort of avoiding puncturing the balloon. On the other hand, internal illiac artery ligation may be more advantageous if the surgeon is experienced.

Septum resection using hysterescopy is safe, rapid and efective, but some late complication of it may be seen as uterine rupture or dehiscence of uterine wall during pregnancy due to myometrial damage. We present a case of recurrent large uterine fundal dehiscence conscecutive to cesarean section in a patient who had previously undergone a uterine septum resection. The patient was a 35-year-old who presented at 39 weeks of gestation (Gravida 2, Parity 1) and was admitted for an elective cesarean section. Her reproductive history included a septum resection which resulted in uterine perforation, and one previous cesarean section in which a large fundal defect was found and repaired. Then the examination had shown an aproximately 5 cm large uterine fundus defect including all three layers of uterus which had been repaired. Perforation or excessively deep incision of uterine fundus during hysteroscopic metroplasty may cause chronic weakness of the uterine wall especially at fundal localization. Our case was an incidental uterine wall dehiscence during cesarean section. Patients with an uterine septum resection history should be followed up carefully for uterine rupture during pregnancy.

We report a patient who became pregnant while on tamoxifen treatment for breast cancer and who elected to continue her pregnancy. The normal child was delivered except for a right renal pelvicaliceal dilatation. The use of tamoxifen in pregnancy is complex, but is not necessarily associated with fetal harm. The relatively high frequency of severe congenital abnormalities indicates that it is prudent to stop tamoxifen before pregnancy.

Background: Therapeutic anticoagulation is required for all patients with prosthetic mitral valves. Anticoagulation with warfarin is recommended; however, warfarin is teratogenic in early pregnancy and therefore alternate anticoagulation regimens are suggested for pregnant patients. Case: A 28-year-old gravida 2, para 1 woman at 36 weeks’ gestation with a prosthetic mitral valve and a history of a corrected anomalous origin of the left coronary artery arising from the left pulmonary artery presented in labor. She underwent a spontaneous vaginal delivery complicated by a postpartum hemorrhage necessitating a hysterectomy. Conclusion: Management of mechanical valves in pregnancy is controversial. The provider must weigh the risks of life threatening valve thrombosis and malfunction against the risk of significant hemorrhage. This case report reviews peripartum anticoagulation protocols and management of massive hemorrhage in patients with prosthetic mechanical valves.

Spontaneous hematoma of the umbilical cord due to rupture of an umbilical cord vessel is a rare obstetrical complication which represents a severe cause of fetal distress with a 50% of reported fetal demise. Although several risk factors have been suggested, the cause of this disorder remains unknown. Herein we describe two cases of term deliveries with spontaneous umbilical cord hematomas which resulted in live births. In both cases the diagnosis was made intrapartum and was confirmed by a histopathologic examination.

Anencephaly is a serious neural tube defect, in which the brain and cranial vault are grossly malformed. It occurs due to failure of cranial neurulation during embryonic development of cranial tissues. Anomalous placental attachment on an anencephalic head of a newborn is extremely rare. We report two cases of anencephaly in which the placenta were anomalously attached on an anencephalic head.

Extended-spectrum β-lactamase sepsis with concurrent uterine incision dehiscence after cesarean section with T-shaped incision for chorioamnionitis occurred in a 29-year-old patient after her first delivery. Following an exploratory laparotomy with a diagnosis of necrosis of the anterior uterine wall, a uterine negative-pressure wound treatment (NPWT) was performed, successfully avoiding hysterectomy and enabling secondary suture of the uterine wall.

Aim: To assess the efficacy of selective termination in improving pregnancy outcome in very early preterm premature rupture of membranes (PPROM) in twin pregnancies. Methods: A total of six dichorionic twin intracytoplasmic sperm injection (ICSI) pregnancies complicated with very early PPROM between 17+5 and 19+3 gestational weeks were admitted to our hospital and were managed by selective termination of the member with ruptured membranes and followed up. Two cases were twins reduced from triplets at our unit (33%). The fetuses with ruptured membranes were subjected to feticide by intra-cardiac injection of potassium chloride after a mean of 3.5 days following PPROM. Results: The overall PPROM-delivery/miscarriage time-interval was 80 days using the proposed management scheme. Two cases ended with total pregnancy loss at 21+ and 23+ weeks, respectively. Four cases progressed successfully beyond 29 weeks, reaching an average of 35+5 days. Conclusions: The handling of these six twin PPROM cases as described produced a healthy baby to take home in four instances, resulting in a success rate of 67%, whereas the implementation of a more conservative approach using antibiotics and steroids is expected to lead to a survival rate of around 15% and a handicap rate up to 50%.

We report on a 35-year-old woman who presented at 36 weeks of gestation with headaches and arterial hypertension. She was discharged after ruling out pre-eclampsia. The next day she returned with worsening headaches and an onset of Horner’s syndrome. A magnetic resonance (MR) angiography showed extensive dissection of the right-sided internal carotid artery. Anticoagulation and antihypertensive therapies were initiated after delivery of the baby by caesarean. The patient recovered fully. Headache in pregnancy is not always due to pre-eclampsia. Carotid artery dissection (CAD) is a rare but severe cause of headache that typically presents with neck pain and focal neurologic symptoms. Once the diagnosis is established, an immediate treatment should be started in order to minimise damage, especially ischaemic lesions.

Heterotopic pregnancies are an unusual phenomenon, which have recently become more prevalent with assisted reproductive technologies (ART). Triplets that are part of a heterotopic pregnancy are exceedingly rare. Here, we describe a case of a woman who presented at 15+1 weeks of gestational age with a known monochorionic-monoamniotic intrauterine pregnancy with several days of abdominal pain with an otherwise unremarkable gastrointestinal (GI) assessment. Salpingectomy was performed, and pathology revealed chorionic villi within the fallopian tube consistent with a heterotopic triplet pregnancy. This pregnancy was conceived spontaneously. Even without the prior use of ART, physicians need to be aware of the risk of heterotopic pregnancy in a patient with a known twin gestation. In addition, this case highlights how heterotopic triplets can present even within the second trimester.

Severe major limb abnormalities of the fetus found by antenatal ultrasound screening are often difficult to be accepted by pregnant women. We experienced two cases with fibular aplasia, tibial campomelia, and oligosyndactyly (FATCO) syndrome, and Cornelia de Lange syndrome (CdLS). Appropriate perinatal care coordinated by obstetricians, pediatric specialists, genetic counselors, nurses, and social workers successfully ensured the better acceptance of the parents toward the severe anomalies complicated in the newborn. In this report, we described the two cases of patients with fetuses prenatally diagnosed with severe fetal limb anomalies.

Background: Mitoxantrone (MIX) is a chemotherapeutic agent used in aggressive multiple sclerosis (MS). It is considered a potential human teratogen and it is classified by the US Food and Drug Administration in pregnancy category D. There are some cases reported of MIX exposure in the pregnancy or preconception period, four in polytherapy in oncological patients and two in MS women. In the first MS case, the baby had low birth weight; in the second the infant suffered from the Pierre Robin sequence. Case history: We describe a 24-year-old female with MS. She started MIX treatment after 4 months from diagnosis, receiving a cumulative dose of 60 mg/m 2 and a total of six infusions since discovering she was pregnant. The last infusion was after the supposed conception day. The pregnancy was regular, with growth restriction during the entire period. On week 39, the patient delivered a healthy baby. Her weight was 2.314 kg (<5 th percentile), the length 45 cm (<5 th percentile), and the cranial circumference 30 cm. Conclusions: We described the third case of MIX exposition in MS-pregnant patients. The only consequence was low birth weight. It is important to collect all the accidental MIX exposition in pregnancy to have more safety data.

Background: Intrauterine blood transfusion is an important treatment of foetal anaemia. Although the standard access to the foetal vasculature for transfusion is the umbilical vein, the intracardiac route is used when foetal or placental positions make other accesses technically challenging. Intrauterine, intracardiac blood transfusion is associated with complications including haemopericardium, damage to cardiac tissues and foetal bradycardia. Highlights of the present report: We report a case of monochorionic twins with twin anaemia-polycythaemia sequence (TAPS). Intracardiac, intrauterine blood transfusion of the donor twin was complicated by haemopericardium and sustained bradycardia which necessitated delivery by emergency caesarean section. Postnatally, the bradycardia was sustained and was diagnosed electrocardiographically as heart block, which spontaneously reversed on the second day after birth. The management of heart block in the neonatal period is discussed. Conclusion: Foetal intracardiac intrauterine blood transfusion can be associated with transient congenital heart block (CHB).

Background: Vertical Zika virus (ZIKV) transmission is actively being studied. Prior cases of ZIKV in pregnancy have suggested an association with infection and adverse fetal outcomes. We describe two cases of maternal illness and their respective pregnancy courses. Case 1: A 30-year-old Hispanic female presented with rash, fatigue, and chills after noticing mosquito bites in Honduras. Fetal anatomy appeared normal on ultrasound at 16 and 17 weeks. ZIKV RNA reverse-transcriptase-polymerase-chain-reaction (RT-PCR) was identified in her serum and amniotic fluid. She opted for pregnancy termination. Fetal serum and tissue analysis confirmed ZIKV infection. Case 2: A 28-year-old Hispanic female presented with rash, fever, and fatigue after sexual intercourse. Her ZIKV serum RNA RT-PCR was positive and amniotic fluid was negative. Fetal anatomy appeared normal at 20 and 22 weeks and her pregnancy remains ongoing. Conclusion: The effects of maternal ZIKV infection in early pregnancy can vary.

A case of neonatal pyloric stenosis, presenting very early in life, accompanied by massive aspiration is described. We speculate that early intrauterine exposure to maternal azithromycin therapy was linked to the disease.

Water immersion of labouring women during the first stage and second stage of labour significantly reduces analgesia requirements and increases women’s reported satisfaction with pushing, without adversely affecting labour duration, operative delivery rates, or foetal wellbeing. However, immersion during the third stage of labour is associated with potential serious complications that are not seen with land-based birth. Here, we present a case report of a baby born via water birth. The report illustrates increased risk of significant perinatal morbidity associated with water birth.

Thoracoschisis is an extremely rare congenital anomaly associated with limb body wall defect and diaphragmatic hernia. We describe a case of a female infant who was noted at birth to have tissue coming through a left sided thoracic defect next to an accessory nipple. The stomach bubble was displaced superiorly on radiographs. At surgery the tissue was attached to the left lateral lobe of the liver and was protruding through the chest wall via an intercostal defect below an eventrated diaphragm. The tissue was resected and the defect closed. Pathological examination was consistent with a mesenchymal hamartoma. The diaphragm may have formed abnormally in this case due to the presence of the mesenchymal hamartoma in this location.

Neonatal myocardial infarction (MI) is a very rare but potentially life-threatening condition with an approximated mortality rate of 80%. Congenital heart disease, anomalous coronary artery anatomy, thromboembolism, coagulopathy, birth asphyxia or myocarditis have been suggested as possible causes of MI. Here we report the case of a premature infant who died at about 40 h of life from a massive MI. Autopsy revealed an occlusive thrombus in the right coronary artery. An isolated prothrombotic status, characterized by a double copy variant of the MTHFR A1298C mutation, was identified at the postmortem genetic studies as a possible explanation for the coronary artery thrombosis. No other risk factors were detected.

Acrocephaly is a common neonatal craniofacial malformation. Saethre-Chotzen syndrome (SCS) is one of the acrocephaly related syndromes less frequently described in the literature. A female newborn term was admitted to our Neonatal Unit to study craniofacial dysmorphia without family history of interest. Pregnancy, childbirth and the neonatal period were uneventful. She had exotropia, short anterior-posterior cranial diameter, flat occiput and wide normotensive anterior fontanelle (beginning at the nose root, continuing through the sagittal suture with the posterior fontanelle) without syndactyly. The scanner imaging confirmed an acrocephaly with fusion of bilateral coronal sutures. We initially suspected a cranyosinostosis due to a Crouzon syndrome or SCS. After differential diagnosis and genetic study the patient was diagnosed as having SCS due to a de novo TWIST1 gene mutation. The craniofacial dysmorphias were corrected early by neurosurgical with good results. This case shows a new example of the phenotypic and genotypic variability of these TWIST1 gene mutations.

Incidence of pneumopericardia in neonates has reduced significantly since the routine administration of surfactant and synchronised modes of ventilation. The majority now occur secondary to the more common air leaks, e.g. pneumothorax, pneumomediastinum, pulmonary interstitial emphysema (PIE); although there are case reports of spontaneous pneumopericardia in the absence of known risk factors. In most cases the air will resorb without active management but if a tension pneumopericardium develops urgent drainage is required to prevent cardiovascular compromise and death. We present a rare case of iatrogenic tension pneumopericardium in a preterm baby secondary to chest drain insertion for a pneumothorax. The resulting air leak was sufficient to require surgical repair via a median sternotomy. This is a previously unreported complication of chest drain insertion in a neonate, and highlights the importance of careful drain placement.

Raynaud’s phenomenon is a paroxysmal and recurrent vasospasm phenomenon characterized by tricolour changes in extremities, commonly hands and feet, triggered by exposure to cold. When isolated it is described as primary, and secondary when associated with other medical conditions. It is usually more common in young adults and is rare in children and very rare in infants. Here, we report a case of Raynaud phenomenon in the immediate postnatal period and review the medical literature on this subject.

Background: Group B Streptococcus (GBS) is the most common pathogen responsible for perinatal bacterial infections. While the early-onset (EO) disease typically presents with pneumonia or sepsis, bacteremia and meningitis represent usual presentation of late-onset (LO) disease. Other clinical manifestations are relatively rare. Highlights: Here we describe an infant with a brain abscess due to a late-onset, GBS serotype I infection. A previously healthy 42-day-old baby presented with insufficient sucking, vomiting, irritability and fever. Cerebrospinal fluid (CSF) analysis, cultures and magnetic resonance imaging (MRI) confirmed the diagnosis of type I group B streptococcal meningitis with brain abscess. The patient made full recovery after a 4-week course of treatment with meropemen and ampicillin. No surgical drainage of the abscess was required. At a 3-year follow-up, the patient had a normal global development with no neurological sequelae. Conclusions: Brain abscess due to GBS late-onset infection is very rarely described. Furthermore, type I GBS is infrequent in late-onset disease. Therapeutic choices in these neonates are challenging because of lack of standards. A long-term follow-up of late-onset disease survivors is mandatory to exclude late developmental impairment.