Emergency Lower Segment Caesarean Section Research Articles

Anaesthetic management of a patient with sub-valvular aortic stenosis for emergency lower segment caesarean section: A case report

Sub-valvular aortic stenosis (SAS) occurs due to a fibrous membrane or a muscular narrowing causing left ventricular outflow tract obstruction. The physiological changes of pregnancy may exacerbate the cardiac condition posing significant challenges for anaesthesia and surgery. A 34 years primigravida, with 32 weeks gestation, a known case of sub-valvular aortic stenosis presented in the emergency room in view of leaking/bleeding per-vagina. Risk factors such as tachycardia, decrease in afterload, preload and increased left ventricle contractility lead to exacerbation of the obstruction and should be avoided. We report a successful anaesthetic management of her lower segment cesarean section while balancing the physiological changes of pregnancy superimposed by pathology of the disease.

Challenges in managing postoperative pulmonary embolism after cesarean section

Postoperative acute pulmonary embolism (APE) can be a life-threatening emergency and is associated with very high mortality. Approximately two-thirds of patients, who died of pulmonary embolism, die within the first hour after the presentation. We report a case of APE following an emergency lower segment cesarean section (LSCS) because of severe fetal distress. This 37-year-old female with no previous medical or surgical history underwent LSCS under general anesthesia. The surgery was uneventful and she was extubated uneventfully at the end of surgery. Six hours after surgery, there was a sudden drop in oxygen saturation on pulse oximetry, tachypnea which raised the suspicion of APE. An urgent chest radiograph computed tomographic pulmonary angiography (CTPA) and transthoracic echocardiogram along a sample for D-dimer were ordered immediately. CTPA was consistent with APE involving the main pulmonary artery. Given immediate postoperative status, therapeutic anticoagulation was done using low-molecular-weight heparin. The patient was discharged 10 days later. APE is a potentially high-risk event that can be challenging in the postoperative period. A high index of suspicion and therapeutic anticoagulation with meticulous monitoring is required in such cases to reduce morbidity.

Anesthetic Dilemma for Management of Parturient with Severe COVID-19 Pneumonia for Emergency Lower Segment Cesarean Section

Anesthetic Dilemma for Management of Parturient with Severe COVID-19 Pneumonia for Emergency Lower Segment Cesarean Section

A Prospective Case-Control Study to Compare the Clinical Outcomes and Metabolic Profile in Neonates Born to Diabetic Mothers in a Tertiary Care Armed Forces Hospital, India

Introduction: The prevalence of gestational diabetes mellitus (GDM) is on the rise especially in women of Asian ethnicity. GDM carries with it a multitude of foeto-maternal complications, the management of which is still a challenge, especially in developing countries. Methods: This was a hospital based prospective case control study conducted on 100 neonates to compare clinical outcomes and metabolic profiles in neonates of diabetic mothers and neonates of non-diabetic mothers over a period of two years. Results: The mothers in GDM group had 66% emergency lower segment caesarean section (LSCS) compared to 32% in non- GDM group (p = 0.001). The infants of diabetic mothers (IDM) had statistically significant higher percentage of preterm births, NICU admission, hyperbilirubinemia, hypoglycaemia and polycythemia. The anthropometric and cord blood parameters (Haemoglobin, haematocrit, platelet, calcium and bilirubin) were comparable in both the groups. Conclusions: GDM poses significant risks to both mother and neonate, however optimal glycemic control and meticulous monitoring and treatment protocols can reduce the incidence of certain known complications.

Diagnostic Accuracy of Lower Uterine Segment Scar Thickness ≤1.6mm in Prediction of Scar Dehiscence in patients

Background: Cesarean section uterine scar dehiscence (CSD) is a rare but notable complication of Lower segment cesarean section (LSCS) surgery. The cause for a uterine scar dehiscence is based on the etiology behind the uterine scar defect or any event that would predispose the cesarean scar to dehisce. Globally accepted option for assessing the CS scar is transvaginal ultrasonography of the non-pregnant uterus. Objective: To determine the diagnostic accuracy of lower uterine segment scar thickness≤1.6mm in the prediction of scar dehiscence in patients with previous one LSCS who are undergoing repeat LSCS after trial of labour taking intraoperative findings as gold standard. Material and methods: This cross sectional study was conducted in Services Hospital, Lahore for 6 months. The Non probability consecutive sampling technique was used to include women with previous one LSCS at 36-38 weeks were asked to get their TVS done for scar thickness. Women with scar thickness≤1.6mm and scar thickness>1.6mm were identified. Their intraoperative findings of scar dehiscence were confirmed. All the data was entered and analyzed on SPSS version 20. Results: The mean age of patients was 29.87±6.07 years. The emergency LSCS was done in 599(49.1%) patients and elective LSCS was done in 621(50.9%) patients. The sensitivity, specificity & diagnostic accuracy of TVS was 98.31%, 99.05% & 98.69% respectively. Conclusion: According to our study results the TVS for uterine scar is a very useful and effective tool in the prediction of scar dehiscence in patients with previous one LSCS taking intraoperative findings as gold standard. Keywords: Transvaginal sonography, TVS, Uterine, Scar, dehiscence, LSCS, Intraoperative

Comparison of Postoperative Pulmonary Outcomes in Patients Undergoing Cesarean Section under General and Spinal Anesthesia: A Single-Center Audit.

Introduction:Regional anesthesia (RA), i.e., spinal or epidural anesthesia when performed for lower segment cesarean section (LSCS) provides excellent surgical conditions, avoiding manipulation of the maternal airway, maternal satisfaction, and good postoperative analgesia. However, in situations like fetal distress (fetal heart rate abnormalities), obstetric indications (abruption of placenta, antenatal placental bleeding, cord prolapse), maternal refusal for RA, contraindications to neuraxial anesthesia (anticoagulation, coagulopathy), and at times failed RA general anesthesia (GA) is administered. Several studies have demonstrated greater mortality and morbidity when LSCS is done under GA when compared to neuraxial block.Methods:After necessary approval, we retrospectively reviewed data over a period of 1 year (January 1, 2020–December 31, 2020) of LSCS under GA versus RA. The aim was to compare immediate postoperative complications, postoperative pulmonary complications up to 4 weeks from the time of elective and emergency LSCS under either RA or GA.Results:Of the 753 patients who underwent LSCS in one calendar year, there were 272 (36.12%) elective and 481 (63.87%) emergency LSCS. The number of elective LSCS under neuraxial block was 219 (29.09%) and under GA were 53 (7.03%). Emergency LSCS done under neuraxial block were 268 (35.59%) and under GA were 213 (28.28%). There were no adverse pulmonary complications at the end of 4 weeks in either group.Conclusion:RA provides maternal satisfaction and excellent perioperative analgesia in LSCS. Safe GA can be achieved with proper airway planning, if case is attended by at least two anesthesiologist with adequate preoperative fasting, and postoperative monitoring.

COVID-19 in Pregnancy: A Maternal Compromise

Few studies have reported the effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on pregnancy albeit the exact mechanism of maternal compromise requiring escalated management is not known. This case demonstrated how a pregnant woman deteriorated and recovered from COVID-19 after delivery. A 37-year-old lady, G4P3, at 29 weeks gestation presented with reduced fetal movement, fever, chest pain and cough, with a background of gestational diabetes. She was proven positive for COVID-19 and was started on treatment promptly. Initially, she was maintaining her oxygen saturations but later deteriorated despite maximum oxygen therapy. She was escalated to the Intensive Care Unit (ICU) and treated with non-invasive mechanical ventilation requiring up to a FiO2 – 0.7. In view of the patient's best interest, multiple Multidisciplinary Team discussions took place and unanimously decided to proceed with emergency lower segment caesarean section under spinal anaesthesia which was uneventful. She made gradual recovery and was discharged from ICU after 2 weeks. During her admission, she was found to be MRSA positive from her Caesarean section wound and was treated accordingly. Both mother and baby were fit for discharge after 1 month of admission. There is a lack of evidence regarding implications of COVID-19 on pregnancy. Gestational diabetes on top of the physiological immunosuppressed status may put pregnant women in a vulnerable group. Further studies are required to identify factors generating increased rate of surgical intervention, preterm deliveries, and ICU admission in COVID-19 positive pregnancies.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S5

A COMPARATIVE STUDY BETWEEN CLOSURE VERSUS NON-CLOSURE OF PERITONEUM DURING CAESAREAN SECTION

AIMS : To assess the short term outcome of closure versus non-closure of both visceral and parietal peritoneum during caesarean section on basis of Duration of surgery (to compare operative time in both groups),Post-operative pain,Use of analgesics,Return of bowel movements and Postoperative febrile episodes STUDY SETTING: This study was conducted in Department of Obstetrics and Gynecology , Guru Gobind Singh Medical College and Hospital, Faridkot. STUDY DESIGN: This was a randomized controlled trial of over 300 patients consisting of 2 groups. Group 1 undergoing closure of peritoneum (control group) and Group 2 with non-closure of peritoneum (study group). The study was approved by the Institutional Ethics Committee. Methods and Material: Atotal of 300 cases undergoing emergency or elective lower segment caesarean section were recruited for the study . The study was approved by the Institutional Ethics Committee. After a detailed history, general physical examination, obstetric examination and routine investigations, informed consent was taken from each patient for participation in the study. Group allocation was done using Microsoft excel where randomization was done using serial number of patients prior to commencement of the study and the women were randomly allocated to one of the two groups (closure or non-closure group 150 in each) . Results: In the present study, mean age of the patients of the closure group and non-closure group was 29.2 years and 28.1 years respectively. Mean duration of procedure among patients of the closure group and non-closure group was 39.69 minutes and 32.26 minutes respectively.Among the patients of the closure group, mean VAS(Visual Analogue Scale) at immediate postoperative period, at postoperative 6 hours, postoperative 12 hours and postoperative 24 hours was found to be 4.8, 6.33, 4.61 and 3.86 respectively. In the present study, 8 percent of the patients of the nonclosure group while 10.4 percent of the patients of the closure group had incidence of postoperative febrile episode . Mean time for returning of bowel movements for the patients of the closure group and non-closure group was 1.72 days and 1.49 days respectively. Mean duration of hospital stay among the patients of the closure group and non-closure group was 2.3 days and 2.06 days respectively . Postoperative wound infection was present in 1.6 percent of the patients of the closure group and 1.6 percent of the patients of the non-closure group. Postoperative wound dehiscence was present in 0.8 percent of the patients of 55 the closure group and 0.8 percent of the patients of the non-closure group . Conclusions: Avoiding the closure of visceral and parietal peritoneum at caesarean delivery is associated with lesser operating time, decreased incidence of febrile morbidity and lesser need for postoperative analgesics. Hence , routine closure of peritoneum at caesarean section can be avoided.

SPINAL ANAESTHESIA USING TAYLOR’S APPROACH SAVES THE DAY IN OBESE PARTURIENT.

Subarachnoid block is commonly employed for caesarean deliveries, by virtue of its simplicity in terms of performance, safety for the parturients as compared to general anesthesia. The case history of a 27-yearold female parturiant patient is presented. She was posted for emergency lower segment caesarean section in view of primigravida with breech presentation in labour . She was obese with bodyweight of 102 kg. She had a thick scaly plaque over the back in midline from L1 to L5 area, which is contraindication for administration of spinal anaesthesia via standard median and paramedian approach . Taylor’s approach for administration of the same was tried and proved successful, thus saving the patient from receiving general anaesthesia .

English

Fine gauze spinal needles are known to decrease the incidence of postdural puncture headache (PDPH) in patients undergoing spinal anaesthesia. We present a rare case of syncopal attack in a patient posted for caesarean section. A patient undergoing elective surgery with inadequate anxiolysis can have a rare chance of a syncopal attack. Hence, high level of suspicion and management of a vasovagal attack is vital. The most common mechanism of syncope is reflex mediated, which can be ‘neurally’ or ‘vasovagally’, and it characteristically develops in the sitting or upright position but may occur in supine position also.1,2 It is characterized by a rapid onset, brief duration, and with a spontaneous recovery. Anxious and apprehensive patients prior to any surgical or anaesthetic procedure can lead to a vasovagal syncope, especially in young females.3 Medline search did not reveal any case report regarding the vasovagal syncope just after spinal needle insertion in young females undergoing spinal anaesthesia. Spinal anaesthesia is the most common anaesthesia performed for lower segment caesarean section (LSCS). A case of syncopal attack with sequence of events, during the insertion of a 25 G Whitacre spinal needle, in a parturient posted for emergency lower segment caesarean section, is discussed here.

Disseminated Peritoneal Leiomyomatosis: A Case Report of an Incidental Finding During an Emergency Caesarean Section and a Review of the Literature

Aim: To present the case report of an incidental finding of disseminated peritoneal leiomyomatosis (DPL) found during an emergency caesarean section in a young Nigerian woman who presented with slow progress in labour and maternal exhaustion.
 Presentation of Case: We present the case of a 35-year-old unbooked primigravida with previous myomectomy who presented with maternal exhaustion and slow progress in labour and subsequently had an emergency lower segment caesarean section. At surgery, multiple firm to hard nodules of varying sizes were seen scattered throughout the peritoneum. Histological examination and immunohistochemical analysis of the nodules showed features consistent with disseminated peritoneal leiomyomatosis. Clinical and radiological follow-up for 1 year was uneventful.
 Discussion: DPL is a rare benign smooth muscle tumour that clinically and macroscopically simulates disseminated intra-abdominal or pelvic malignancy. It occurs predominantly in women of child bearing age and is mostly discovered incidentally. The occurrence of DPL in association with pregnancy and uterine leiomyomas was also corroborated in this index case as pedunculated and intramural uterine nodules were also seen during surgery.
 Conclusion: Disseminated peritoneal leiomyomatosis is a rare benign disease which may be misdiagnosed as disseminated or metastatic intra-abdominal malignancy. Therefore, a high index of suspicion is required for accurate diagnosis and proper management.

English

A 30-year-old female, gravida-3, para–1, live–1, abortion–1, admitted in Sri Ramachandra Institute of Higher Education and Research (SRIHER) at 37 weeks and 6 days of gestation–planned for elective lower segment Caesarean section. Growth scan done at 37 weeks showed fetal growth restriction (estimated fetal weight-EFW at 3rd centile) with uterine artery Doppler showing high resistance flow. She had mild anaemia (haemoglobin 9g / dl), B negative blood group, indirect Coomb’s test was negative, and injection anti D was not given antenatally. She had an uneventful antenatal period. In 2013, at 23-years of age, she was referred to SRIHER with high grade fever and lower abdominal pain for one-week duration. She had history of dilatation and curettage done one week back for missed abortion. Pelvic ultrasound and computed tomography showed an adnexal mass with air pockets suggestive of a pelvic abscess. She was taken up for emergency laparoscopy which revealed a pelvic abscess walled off by omental and bowel adhesions along with perforation on the upper part of the posterior surface of uterus with extensive sloughing. In view of the nulliparous status of the patient conservative management was opted for and decision was taken to preserve the uterus under stepped up antibiotic cover. Thorough peritoneal wash was given, and intraperitoneal drain was kept. Patient was intensively monitored. Though she developed features of evolving sepsis prompt critical care management resulted in her steady recovery without undergoing hysterectomy.1 In 2018, (G2A1) patient was planned for elective lower segment Caesarean section (LSCS) at 37 weeks. However, she came to our institute at 33 weeks and 4 days of gestation in early labour. In view of history of previous septic abortion with uterine perforation, she delivered by emergency lower segment Caesarean section. Baby was a late preterm girl, weighing 1.9 Kg, cried immediately at birth. Placenta and membranes were delivered in toto. Intraoperative period was uneventful. Posterior wall of uterus did not show any signs of the previous perforation. Postoperative period was uneventful.

Achondroplasia and emergency caesarean section: A case report

Achondroplasia is the commonest variety of rhizomelic dwarfism, which results from abnormal cartilage formation at epiphyseal growth plates. The peculiar facial features, bony deformities and systemic abnormalities often pose a difficulty in administration of anesthesia, particularly in the parturients. There are very few reported cases of spinal anesthesia in achondroplastic parturients, because of its feared high risks. We reported, two cases of achondroplastic parturients with short stature, planned for emergency lower segment caesarean section (LSCS), in view of cephalo-pelvic disproportion under spinal anesthesia. We discussed the anesthetic issues to achondroplastic parturients and finally did under spinal anesthesia. Besides, a myriad of problems encountered in these patients warrant a careful pre-anesthetic evaluation to warrant patients' safety and affirmative procedure outcomes.

Airway changes before & after delivery-does labour has any effect on the modified mallampati score?

Background: Changes in modified mallampati grade occur with the progress of pregnancy, labor, and delivery due to various reasons. This could lead to unanticipated difficulties in airway management, especially if the parturient were to undergo a surgical procedure in the postpartum period. Our study aimed to evaluate the change in airway parameters after delivery in parturient undergoing lower segment cesarean section (LSCS) under spinal anesthesia. Materials and Methods: This study was conducted at Vardhaman Mahavir (VMMC) and Safdarjung Hospital over a period of 18 months. A total of 160 patients posted for either elective or emergency cesarean section under spinal anesthesia were enrolled in the study (80 in each group). Airway parameters including modified mallampati grade (MMPG) were measured at various time intervals – before cesarean section (T1) and 2 h (T2), 6 h (T3), 24 h (T4), 48 h (T5), and 72 h (T6) after delivery and analyzed statistically. Results: Changes in MMPG occurred in 71.25% of cases in the emergency group as compared with 40% of cases in the elective group (P = 0.0001). The mean MMPG was significantly higher from 2 h up to 72 h after LSCS in the emergency group (having more patients in active labor). (P = 0.0001). Maximum changes in MMPG occurred 6 h after delivery in both groups. Normalization of MMPG to its precesarean value occurred earlier in elective patients (P = 0.0005). An association was found between the duration of labor and normalization of changes in MMPG to its preoperative value (P = 0.023). Conclusion: Airway changes in pregnant women are seen to worsen after emergency LSCS under spinal anesthesia and are affected by prolonged labor. Therefore, the maternal airway should be reassessed after the delivery of the baby, for any surgical procedure thereafter.

Appraisal of caesarean section incidence and indications at manipal teaching hospital, Pokhara, Nepal

Background: Worldwide lower segment caesarean section (LSCS) is the most commonly performed obstetric operation. Though it’s a lifesaving procedure it is sometime associated with both short and long term risk which can extend many years beyond current delivery and affect health of mother, fetus and future pregnancy.
 Aims and Objective: The study aims to examine the incidence and indication of caesarean section at Manipal teaching hospital.
 Materials and Methods: A retrospective descriptive study of 2140 cases was carried out at a teaching hospital in Pokhara, Nepal. Data regarding total number of vaginal delivery and caesarean section performed in 1 year duration from August 2019 to July 2020 was obtained from the operation record book and medical record section of hospital. Other information regarding age, parity, gestational period and indication of cesarean section were obtained and depicted in tabulated form. The collected secondary data has been analyzed employing frequencies and percentage.
 Results: During the one year study period, 2140 deliveries were made out of which 1170 (54.7%) cases underwent caesarean section. Out of those cases 78.8% of women underwent emergency LSCS. Most of the women were in the age group of 21-30 years (69.2%). In 81.2% cases caesarean was done between 38-42 weeks gestation. 52.3% of cases were multigravida, 43.8% were primigravida and only 3.1% were grand multigravida. Most common indication of caesarean were fetal distress (23.7%), previous LSCS (23%), cephalopelvic disproportion (15.6%), oligohydramnios (11%) followed by breech, preeclampsia, eclampsia and non-progress of labour.
 Conclusion: This study revealed that the incidence of caesarean section was high in the hospital and majority of the patients who underwent caesarean section had an emergency caesarean section. The commonest indications were fetal distress and repeat cesarean section. The issue requires further investigation to identify reasons for high CS rate and raises necessity of policy guidelines and intervention in order to prevent possible unjustified use of surgical delivery.

Anaesthetic management of a parturient patient with peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare life-threatening clinical entity of unknown aetiology. The hallmark of the disease is the onset of decreased left ventricular ejection fraction either in late pregnancy or puerperium. The clinical presentation and the basic and intensive interventional strategies of the disease are more or less similar to that of dilated cardiomyopathy due to any other cause. Apart from intensive care management, these patients also require anaesthetic intervention for the management of painless labour for either vaginal or operative delivery. Favourable maternal and foetal outcomes require haemodynamic goals to be always kept in mind while choosing the technique and drugs to provide anaesthesia to the patients with PPCM. We report the case of a patient with PPCM requiring emergency lower segment caesarean section who was managed with titrated epidural anaesthesia.

Torsion of the gravid uterus: A rare cause of abdominal pain

Uterine torsion in pregnancy is a rare clinical entity with a non-specific clinical presentation. Here, we present a case of uterine torsion,which was diagnosed at laparotomy done for the lower segment cesarean section (LSCS) in a case of central placenta previa with thefetus in transverse lie. At 36.4 weeks period of gestation, the patient complained of severe left-sided abdominal pain which was notsuggestive of labor. This abdominal pain was refractory to analgesics. Emergency LSCS was done which confirmed uterine torsion aswell as anterior sacculation.

Frequency of Post-Operative Wound Contamination in Bakhtawar General Hospital, Jamshoro

Background: Surgical site wound infection (SSI) imposes a great challenge worldwide. It is the third most commonly reported nosocomial infection. The objective of the study was to assess the frequency of postoperative wound infections in a newly developed health organization.Material and Methods: This cross-sectional study was conducted from June 2017 to May 2018 in Bakhtawar General Hospital, Jamshoro. A total of 364 cases of surgery, from Obstetrics and Gynecology and General Surgery department were included. Surgical interventions involving an incision were assessed. Infection (SSI) rate was noticed and data was analyzed by SPSS version 18.Results: Healthy discharge rate was 97%. The overall surgical site wound infection rate was 3.1%. These infections were high in genitourinary surgeries (9.09%). Among Obstetrics & Gynecology surgeries, maximum number of SSIs were reported in cases of emergency Lower Segment Cesarean Section (LSCS).Conclusions: The overall rate of SSI for different types of surgeries performed at Bakhtawar General Hospital, Jamshoro was only 3.1%. Frequency of SSI was highest in genitourinary surgeries followed by gastrointestinal and obstetrics and gynecology surgeries, respectively.Key words: General Surgery, Genitourinary surgery, Obstetrics & Gynecology surgery, Post-operative wound contamination

Indications and Adverse Outcomes of Emergency Lower Segment Cesarean Section at 1St and 2Nd Stages of Labor at Al-Elwiya Maternity Teaching Hospital

Background: globally that about 6.2 million unnecessary cesarean sections were done yearly. Oldest surgical operation and it is considered as one of the most commonly performed surgical operations. Objective: To assess the indications and adverse outcomes of emergency lower segment caesarean section at 1st and 2nd stages emergency Caesarean at Al-Elwiya maternity teaching hospital. Patients and method: A prospective cross sectional study conducted for 1 year duration in Al-Elwyia Teaching hospital in the period from the first of Jan. 2018 to the end of Dec. 2018, when 1229 of the women were enrolled. Results: A total of 1229 cesarean sections operations were done in the period of the study, 836 (68%) were 1st stage emergency Caesarean and 393(32%) were in 2nd stage. The most common indications of the caesarean section were the malposition (64.5%). Meconium aspiration Syndrome is the most common perinatal outcome (n=34).Conclusion: The 2nd stage emergency Caesarean shows more maternal and neonatal complications in comparison with 1st stage

Hemorrhagic infarction of hyperreactio luteinalis in spontaneously conceived singleton pregnancy: An uncommon cause of late third-trimester ovarian accident

Ovarian masses complicate about 1%–2% of all pregnancies while posing diagnostic and therapeutic challenges. Most are benign tumors but occasionally, functional cysts, such as theca lutein cysts, may be encountered in pregnancy. These are bilateral ovarian masses associated with high levels of β-human chorionic gonadotropin, thus seen mostly in the settings of trophoblastic diseases, multiple gestations, or following treatment for subfertility. It has also been reported in spontaneous singleton pregnancies. Clinical presentation is variable, ranging from asymptomatic conditions discovered incidentally to acute gynecological emergencies due to ovarian accidents. We report the case of a 29-year-old gravida 2, para 1 + 0, with estimated gestational age of 39 weeks plus 1 day, who had a previous emergency lower segment cesarean section (ELSCS) 3 years ago and presented with 1-h history of sudden-onset, sharp, right-sided, abdominal pain of increasing intensity. There were no history of trauma and no evidence of labor. On examination, she was a young gravid woman, at term, in severe painful distress. Baseline investigations were done, and she had ELSCS and exploratory laparotomy with a right salpingo-oophorectomy for twisted and hemorrhagic right adnexa discovered. Pathologic evaluation of the right ovary revealed an enlarged, dark brown, lobulated ovarian mass comprising multiple cortical cysts separated by a thin wall and containing dark brown fluid, with gray brown and hemorrhagic solid areas. A histologic diagnosis of hemorrhagic infarction on the background of multiple theca lutein cysts in pregnancy was made. She had a good postoperative recovery.