Healthy Baby Boy Research Articles

A case report: Treatment of a patient with ruptured middle cerebral aneurysm in the second trimester of pregnancy.

To summarize the clinical experience of intracranial aneurysm clipping in the treatment of ruptured intracranial aneurysms in the second trimester of pregnancy. A case of ruptured middle cerebral aneurysm in the second trimester of pregnancy was reported. Craniotomy and aneurysm clipping were performed at 24 weeks of pregnancy, and fetal preservation was continued after the operation. The prognosis of the parturient was good and the skull was missing on the operative side. A healthy baby boy was delivered by cesarean section 2 months after the operation, and skull repair was performed 4 months after the operation. During the follow-up for 1 year, the mother and son were healthy and no obvious sequelae were found. Ruptured intracranial aneurysm hemorrhage in mid-pregnancy is a rare and critical case. Summarizing the corresponding clinical experience will help to have a reference plan for the next time when facing a similar situation, and it will help to treat critically ill patients. The treatment of ruptured intracranial aneurysm in mid-pregnancy requires multidisciplinary collaboration, and cranial aneurysm clamping + fertility preservation can reduce the impact of radiation on the fetus and improve the prognosis for both the mother and the fetus.

Management of PCOS Infertility then implementation of Garbhini Parichaya till Full Term by Ayurveda - Case Study

Primary Infertility associated with recurrent pregnancy loss because of Viral infections like TORCH and Polycystic Ovarian Syndrome (PCOS) is a worrisome issue nowadays. In modern medicine, antiviral drugs are the main treatment for TORCH, causing various side effects. Ayurveda being preventive and curative medicinal branch, has good positive outcome in the treatment of TORCH induced BOH and infertility. The Garbhini Paricharya refers to the care given to pregnant lady. It has to be started as soon as the signs and symptoms of pregnancy are seen. The rate of abortions can be prevented by following proper antenatal care detailed in Ayurveda. Presenting a case report of 32-year-old female came to Govt. Ayurvedic college and hospital, Varanasi with 11 years of married life and history of two consecutive spontaneous abortions and wasn’t able to conceive since then. She was detected with PCOS and Positive TORCH infection. Her last USG findings dated 17/01/2023 was right ovarian- PCOS morphology & left ovarian- hemorrhagic cyst 54x60mm + subserosal uterine fibroid 20x27mm in fundal region with complaints of inability to conceive with complaints of delayed menses at interval of 2-6 months with prolonged bleeding with clots for 10-15 days for 7 years (after last abortion). Treatment protocol was based upon Samprapti Vighatan & focused on Prakriti of patient, Dosha Pradhanya Lakshana & Dosha Dushya Sammurchana. She was treated with Jalkumbhi Kshar with Varunadi Kwath for her fibroid and Pushpadhanva Rasa, Kanchanar Guggulu, Ashokarishta etc along with Nasya, Matra Basti and Uttar Basti. After 4 months of treatment, patient was treated successfully with Ayurvedic intervention and Garbhini paricharya with conception and delivery of a full-term healthy baby boy.

Late emergency cervical cerclage placement in a patient with early recurrent pregnancy loss and bicorporeal uterus: A case report

Introduction: Uterine Müllerian anomalies are relatively common among the population, affecting approximately 4% of women, and can lead to various pregnancy-related pathologies. Cervical cerclage, a surgical procedure involving the placement of a stitch around the cervix, has been recognized as an optional treatment to mitigate the risk factors associated with these anomalies. Case Report: A 33-year-old woman with a bicorporeal uterus and a history of early recurrent pregnancy loss, who was diagnosed with a cervical os shortening during her second anatomy screening at 22+3 weeks gestation. A cervical cerclage was performed to prevent preterm delivery, and subsequently. An elective cesarean section was conducted at 37+0 weeks of gestation, resulting in the birth of a healthy baby boy. Conclusion: Although the literature about the effectiveness of cervical cerclage in pregnant women with Müllerian anomalies is limited, this case highlights its potential as an effective treatment option.

A case of vaginal varicosities without rupture after vaginal delivery

HIGHLIGHTS Vaginal varicosities are prone to happen in pregnant women with unspecific causes and multifactorial. The mode of delivery in a pregnant woman with vaginal varicosities is still unknown, but it is not an indication of caesarean section. ABSTRACT Objective: Vaginal varicose is a rare condition characterized by dilated veins in the labia majora, labia minora, and vagina. This case report reported a woman with vaginal varicose who experienced labor without any delivery complications. Case Report: The patient, a 29-year-old woman, gravida 3, para 2, presented with discomfort and swelling in the vagina at 32 weeks of gestational age. Despite reaching 39 weeks of gestation, the vaginal varicosities remained stable and painless. She had no prior history of varicose veins, hypertension, blood abnormalities, malignancy, or contraception usage. Physical examination revealed mild varicosities in the labium and significantly swollen varicosities protruding toward the vaginal introitus. Interestingly, a small varicose vein was also noted on her right leg, previously unnoticed by the patient. At 39 weeks pregnant, she experienced spontaneous vaginal delivery without complications. During the third stage of labor, the vaginal varicosities decreased in size, and no rupture occurred. The newborn, a healthy baby boy weighing 2961 grams and measuring 48 cm, was delivered vaginally. Despite a second-degree perineal tear, blood loss was minimal, and no complications nor rupture arose from the varicose veins. Conclusion: Vaginal varicosities are rare, primarily occurring in multigravida pregnant women between 12 and 26 weeks of gestation. This case highlights that cesarean section is not necessarily indicated in pregnant women with vaginal varicosities. The successful vaginal delivery in this instance resulted in no varicose vein rupture, controlled bleeding, and regression of vaginal varicosities postpartum.

Positive Pregnancy Outcome following First Trimester Dulaglutide Exposure in a Women with Type 2 Diabetes and PCOS: A Case Report

Background: Insulin has been the gold standard treatment for T2DM during pregnancy. However, emerging studies indicate that GLP-1 agonists have shown significant improvement in insulin resistance. Despite promising results, research conducted on pregnant animal models has shown fetal developmental defects associated with GLP-1 agonists. There is scarcity of research conducted on the use of GLP-1 agonists in human pregnancies. This case report describes the exposure to dulaglutide (GLP-1 agonist) during first trimester of pregnancy. Case: A 41-year-old female with type 2 diabetes mellitus and polycystic ovarian syndrome had been taking dulaglutide until 15 weeks of gestation. She delivered a healthy baby boy via cesarean delivery at 36 weeks’ gestation. Conclusion: In our case, exposure to dulaglutide during the first trimester showed no significant developmental effects on the baby. However, current research is insufficient to categorize GLP-1 agonists as safe during pregnancy.

Two Cases of Posterior Uterine Rupture After Foetal Pillow Use; Is It Time To Think Twice About Using the Foetal Pillow?

Introduction: The incidence of caesarean section at full dilatation is increasing, with 10% being emergency cases. The Fetal Pillow device helps elevate the foetal head during such caesarean sections, potentially reducing blood loss and neonatal complications, however the evidence for this has recently been called into question. The authors presented 2 cases of possible complications associated with fetal pillow use. Case 1: A 40-year-old woman with a history of one previous caesarean section opted for vaginal birth after caesarean. After induced labor, the patient experienced fetal distress during pushing, leading to an emergency caesarean section using a Fetal Pillow. During the surgery, a 10cm vertical full-thickness posterior uterine wall rupture was noted, but the baby was delivered safely. The woman recovered well, but in future pregnancies, the patient was advised to have a planned caesarean section at 37 weeks. Case 2: A 36-year-old woman with two previous vaginal deliveries presented in spontaneous labor and ruptured membranes. An emergency caesarean section using a Fetal Pillow was performed due to a delay in the second stage of labour. Intraoperatively a 6cm vertical partial thickness posterior wall dehiscence was noted. The patient delivered a healthy baby boy with an uneventful recovery and was advised for a planned caesarean section in future pregnancies. Discussion: Posterior uterine wall ruptures are very rare but known to occur in labour. The authors reported the first 2 cases in the literature following Fetal Pillow use, raising the question as to whether the Fetal Pillow had any role in causing this rare uterine injury. Evidence on the efficacy and safety of Fetal Pillow remains limited and recent concerns have led to a recall of a significant study. These complications should be reported to ensure patient safety and regulatory awareness. Conclusion: This report presents two cases of posterior uterine wall rupture following the use of Fetal Pillow. It calls for a larger, well run, randomized control trial to analyze the safety of Fetal Pillow use and suggests that all Obstetricians should be educated on alternative strategies for foetal head disimpaction during cesarean sections.

Approach to ovarian torsion with corpus luteum removal in early pregnancy

The ovary’s Torsion is the adnexa’s total or partial rotation around its vascular axis or pedicle. Complete torsion causes venous and lymphatic blockade leading to stasis, venous congestion, hemorrhage, and necrosis. If neglected, it may result in permanent loss of the affected ovary. Ovarian torsion is one of the most critical gynecological surgical emergencies. Therefore, it requires urgent surgical intervention. It is mainly diagnosed by clinical examination and ultrasound. Ovarian torsion is primarily seen in the first trimester of pregnancy. Infertility treatment is a significant risk factor due to ovarian stimulation. We present a case of acute abdominal pain who came to the emergency department of Al Ahli Hospital, diagnosed as right adnexal torsion with viable intrauterine pregnancy at six weeks. Laparoscopic oophorectomy was done by removing the corpus luteum cyst, which supports early pregnancy. Despite its disposal, the pregnancy continued because the hormonal therapy started in doses higher than recommended for threatened abortion. Eventually, she gave birth to a healthy baby boy at 35 weeks.

Live birth using autologous sperm cryopreserved for 26 years.

We report the successful delivery of a healthy baby after intracytoplasmic sperm injection (ICSI) with frozen-thawed autologous sperm, cryostored for 26 years, the longest successful autologous sperm cryostorage reported. Sperm was cryostored for a 15-year-old boy at the time of his cancer diagnosis. Semen samples were frozen with cryoprotectant, using a graduated vapour-phase nitrogen protocol. Straws were stored in a large vapour-phase nitrogen tank until transfer for use. The couple underwent a single ICSI-in vitro fertilisation procedure using the frozen-thawed sperm with a transfer of five fertilised embryos, resulting in the live birth of a healthy baby boy. This reinforces the importance of offering sperm cryopreservation to men who have not completed their family prior to gonadotoxic treatment for cancer or other diseases. As practical, low-cost fertility insurance, it should be offered to any young man who can collect semen and it provides essentially unlimited duration of fertility preservation. Gonadotoxic chemo or radiotherapy treatment for cancer or other diseases usually causes temporary or permanent male infertility. Sperm cryostorage serves as a practical, low-cost insurance to facilitate future paternity. All men who have not completed their families and are scheduled for gonadotoxic treatments should be offered sperm cryostorage. There is no lower age limit for young men who can collect semen. Sperm cryostorage offers essentially indefinite duration for the preservation of male fertility.

Bio-Identical hormone treatment as a functional approach to treat Asherman’s Syndrome

Here we present a case of 30 year old married women suffering from asherman’s syndrome with failed IVF trials and infertility complications. A Holistic approach that includes bioidentical hormone therapy was adopted to help her in regaining fertility. A comprehensive therapeutic plan was followed to treat the patient. It included Optimizing body hormones vitamins, elimination of inflammation, improving Gut and suggesting healthy life style with continual follow up. After 13 months of continual treatment, she got pregnant and delivered a healthy baby boy .No complications during pregnancy and delivery were reported. It is concluded that women with severe Asherman syndrome who are infertile can experience promising reproductive results with quality healthcare.

A homozygous PRKN-associated juvenile Parkinson's disease with pregnancy in China.

Although Parkinson's disease (PD) is the second most common neurodegenerative disorder, pregnancy in patients with PD is a relatively rare occurrence because the most common age of onset of PD is beyond the childbearing age, except in patients with Young-Onset PD (YOPD) caused by parkin RBR E3 ubiquitin protein ligase (PRKN) mutations. In this study, we report the case of a 30-year-old Chinese woman who was affected by PRKN-associated YOPD and was treated with levodopa/benserazide during pregnancy. She gave birth to a healthy baby boy with an Apgar score of 9 through an uncomplicated vaginal delivery. This case further suggests that levodopa/benserazide during pregnancy is safe in the treatment of PRKN-associated YOPD.

Pregnancy and Delivery of a Healthy Baby Boy from a Patient Embryo Cryopreserved for Over 18 Years: A Case Report

Cryopreservation offers semipermanent embryo storage. Although there have been various reports on effects of cryopreservation, there are few regarding preservation for 10 years or more. Here, we describe the delivery of a healthy child to a mother 51 years old, using an embryo cryopreserved for 18.3 years. The patient had four cleaved embryos cryopreserved when she was 32 years old. After more than 18 years, a Day-3, 10-cell stage embryo was transferred during a hormone replacement therapy cycle. The patient became pregnant and gave birth to a healthy boy (3,046 g). This case demonstrates the potential for live births at advanced maternal age by cryopreserving embryos at a young maternal age. To our knowledge, this is the longest cryopreservation period reported for a birth involving transfer of the mother’s own frozen embryo.

Successful Strategy of Pre-implantation Genetic Testing for Beta-Thalassemia (c.17A>T Mutation)-Hb E Disease Using Multiplex Fluorescent PCR and Mini-Sequencing

Objectives: Hemoglobin E disease, c.26G>A variant of beta-globin gene, is the most common hemoglobinopathy in Asia. Compound heterozygotes inheriting Hb E disease and beta-thalassemia generate beta-thalassemia-Hb E disease with severe anemia. This study aimed to develop a pre-implantation genetic testing for monogenic disorders (PGT-M) protocol for beta–thalassemia (c.17A>T mutation)-Hb E disease (c.26G>A mutation) using multiplex fluorescent polymerase chain reaction (PCR) and mini-sequencing. Materials and Methods: bthalw1 primers were used to amplify a beta-globin gene fragment covering both mutations, i.e. beta– thalassemia (c.17A>T) and Hb E disease. D21S11 microsatellite marker was included for contamination detection. Novel mini-sequencing primers were designed and tested for detection of both mutations. Results: Pre-clinical work up of the optimized PGT-M protocol using 20 single buccal cells of a heterozygous subject showed 100% amplification efficiency and 0% allele drop out (ADO) rate for both primers. In clinical PGT-M cycle, 15 embryos were subjected to biopsy. The results showed two normal, one heterozygous for beta-thalassemia, six heterozygous for Hb E disease, one affected for beta-thalassemia-Hb E disease and five with ambiguous results. Two normally diagnosed embryos were chosen for transfer, one singleton pregnancy was obtained. A healthy baby boy was resulted. Postnatal testing confirmed PGT results. Conclusions: Novel PGT-M protocols for beta-thalassemia-Hb E disease using multiplex fluorescent PCR and mini-sequencing were developed and described here. The protocol was applied in a clinical PGT-M cycle and gave rise to one successful pregnancy and consequently a healthy baby boy. Mini-sequencing was proved to be rapid, accurate and cost-effective protocol for PGT-M.

Treating thin endometrium by Ayurvedic Medications: A Case Study

Infertility is one of the most prevalent chronic health disorders involving young adults. Infertility is defined as failure to establish a clinical pregnancy after 12 months of regular and unprotected sexual intercourse. Endometrium is one of the important factors for successful pregnancy. Endometrial thickness is a marker for endometrial receptivity and a prognostic factor for pregnancy. A thin endometrium is generally defined as endometrial thickness less than 7 mm. Thin endometrium adversely affect reproductive performance. A thin endometrium is generally defined as endometrial thickness less than 7 mm. This is a case report of a female patient with thin endometrium with a complaint of inability to conceive for 2 years of regular unprotected intercourse. The menstrual blood is the shedded functional layer of endometrium of the uterus. In Ayurveda, the term rajah is used for menstrual blood. So, this case is considered as Rajah-Kshay and is treated accordingly. The treatment plan includes Rasa & Rakta Pachak (Blood Purifiers) medications and Uttarbasti (Vaginal administration of liquid medicine) of Phalaghrita to increase Dharan kshamata (implantation) of endometrium. During the treatment period this patient’s endometrial thickness increased from 6.1 mm to 9 mm and menstrual flow increased. This led to her conception within 5 months of treatment and she delivered a healthy baby boy.

PS-BPR01-1: SUCCESSFUL TREATMENT WITH ESAXERENONE IN A PREGNANT WOMAN WITH PRIMARY ALDOSTERONISM AND SUPERIMPOSED PREECLAMPSIA

Background: During pregnancy, there is no established treatment for idiopathic hyperaldosteronism (IHA), the most common form of primary aldosteronism (PA) due to bilateral adrenal hyperplasia. Here, we report the case of a pregnant patient with IHA who was successfully treated with esaxerenone, a non-steroidal mineralocorticoid receptor (MR) antagonist. Case: A 39-year-old woman was referred to our outpatient clinic for hypertension with high plasma aldosterone concentration (PAC). Her PAC was 204 pg/mL (radioimmunoassay) and plasma renin activity was 1.2 ng/mL/h at the time of referral. She was diagnosed with PA since the saline-loading test for PA was positive. She had no hypokalemia and computed tomography scans showed no adrenal tumors. Adrenal vein sampling indicated overproduction of aldosterone in both adrenal glands leading to the diagnosis of IHA. She was commenced on nifedipine controlled release (CR) 20 mg daily because she desired to be pregnant. After one year, she became pregnant. Her blood pressure was well controlled until 34 weeks of gestation when her home blood pressure became elevated up to 140/90 mmHg. Although the dose of nifedipine CR was increased to 80 mg daily, her blood pressure increased to 151/97 mmHg and urinary test showed proteinuria of 2 + in 35 weeks of gestation. She was diagnosed with superimposed preeclampsia (SPE) and additionally treated with esaxerenone. Her blood pressure decreased to 120–140/98–100 mmHg and the proteinuria improved to +/-. A successful cesarean section at 37 weeks resulted in the delivery of a healthy baby boy. Esaxerenone was discontinued 2 weeks after delivery, because she was eager to breast-feed the baby and no safety data of esaxerenone in breast-feeding woman was available. Her blood pressure has been well controlled by nifedipine CR 80 mg daily even after 100 days of postpartum. Conclusions: This is the first case of a pregnant woman who was successfully treated with esaxerenone despite being an elderly pregnant woman who had been diagnosed with IHA and developed SPE. Further studies are needed to investigate the efficacy and safety of non-steroidal selective MR antagonist in similar pregnant patients with IHA, to establish better treatment strategy for these patients.

Role of Yoga Prana Vidya (YPV) System Protocols in Infertility Treatment: A Case Study of A 29-Year-Old House Wife with History of Recurrent Spontaneous Miscarriages and Ovarian Cysts

INTRODUCTION: Recurrent spontaneous miscarriage (RSM) affects 1 to 2 % of women causing anxiety and worry for self and family. Ovarian cysts are perhaps the most common issue among women trying to conceive. This paper presents a case of a 29-year-old married woman having ovarian cyst and suffered two miscarriages, was treated successfully using YPV healing protocols. METHOD: This paper used case study method going through patient medical records, healer’s records and patient feedback. RESULTS: The patient experienced successful pregnancy and delivered a healthy baby boy after a C-section procedure. There were no health issues of baby and the mother post-delivery. A follow up after 9 months confirmed that the mother and her baby both were in good health. CONCLUSIONS: YPV system protocols have been established as complementary as well as alternative medicine to treat and cure a variety of health conditions. Further research is recommended. It will be worthwhile to consider imparting a working knowledge of YPV system protocols to frontline healthcare workers including doctors and nurses to enable them to render holistic treatment in a safe process at low cost CONCLUSIONS: YPV system protocols have been established as complementary as well as alternative medicine to treat and cure a variety of health conditions. Further research is recommended. It will be worthwhile to consider imparting a working knowledge of YPV system protocols to frontline healthcare workers including doctors and nurses to enable them to render holistic treatment in a safe process at low cost

Case Report: Successful Pregnancy and Birth of a Healthy Baby with PGT-A for Woman with Advanced Maternal Age

Introduction: The most common cause of failed implantation and miscarriage is embryonic aneuploidy and the risk of aneuploidy increases significantly with increasing maternal age. Pre-implantation genetic testing for aneuploidy (PGT-A) can be an option to improve the prognosis of women with advanced maternal age by extracting 3-5 trophectoderm cells from Day 5 and Day 6 blastocysts for genetic testing. Case History: A 37 years old patient tried to conceive for 5 years was recruited into our PGS research study initiated by Ministry of Health in Singapore. She had 3 previous implantation failure and one miscarriage between 2015-2018. The patient had regular menses every 30-35 days. Antral follicle count was 48 and her husband’s semen analysis was normal with Density 87 million/ml, motility 34% and morphology 4%. Results: Patient underwent an IVF cycle with PGT-A in December 2018 at our IVF Centre. 23 eggs were retrieved, 21 eggs were mature to undergo ICSI and 11 fertilized. The eggs were cultured in EmbryoGen immediately after ICSI and the embryos were transferred to BlastGen on Day 3 for extended culture. A total of 5 embryos were suitable for biopsy, 3 on Day 5 and 2 on Day 6. Embryos were vitrified while waiting for the genetic results. Chromosomal analysis of the biopsied trophectoderm cells was performed using NGS platform. Out of the 5 embryos tested, 2 embryos were euploid, giving 60% aneuploidy rate. One euploid embryo was thawed and transferred in a regulated frozen-thawed cycle in March 2020. The patient became pregnant and delivered a healthy baby boy. She returned in January 2022 to put back the remaining euploid embryo, she was again pregnant. Conclusion: PGT-A for comprehensive chromosome screening in selecting and transferring euploid embryos in assisted reproduction has an immediate impact on implantation, reduces the rate of clinical miscarriages and results in higher live birth rates.

Acupuncture Is Successful for An Infertile Couple with Polycystic Ovary Syndrome (PCOS) And Oligo-Astheno-Teratozoospermia (OAT): A Case Report

This article is a case report on a couple who had difficulty conceiving for 4 years. They wanted to undergo acupuncture to improve their health and increase their chances of conceiving. Four years prior, the wife was diagnosed with polycystic ovary syndrome (PCOS) and primary infertility. She wanted to regulate her menstrual cycle, to help release eggs regularly, to increase the rate of ovulation and the chance of pregnancy. The husband was diagnosed with oligo-astheno-teratozoospermia (OAT). He wanted to improve the quality of his sperm i.e. sperm count, motility and morphology. Results: Acupuncture was done once a week as the sole treatment for each member of the couple over the course of 4 months, which resulted in the female partner becoming pregnant naturally and giving birth to a healthy baby boy. Conclusions: This case suggests that acupuncture is an effective treatment for female patients with PCOS and for male patients with OAT.

Prophylactic therapeutic plasma exchange in pregnant woman with Familial Chylomicronemia Syndrome – A case report

ContextFamilial Chylomicronemia Syndrome (FCS) is an inherited disease where lack of lipoprotein lipase results in severe hypertriglyceridemia that frequently leads to recurrent acute pancreatitis. Pregnancy in patients with familial chylomicronemia syndrome (FCS) post a risk for mother and baby with potential complications (pancreatitis, miscarriage and death). Therapeutic approach includes strict dietary measures and plasma exchange. Despite the development of new drugs for FCS, their safety in pregnancy has not yet been confirmed. Case descriptionWe present a case of a young, pregnant female with FCS who had miscarriage in the past during one episode of acute pancreatitis. Due to the inability to achieve lower TG levels with current therapy, from 27-th week of pregnancy we have started prophylactic therapeutic plasma exchange (two times per week). Patient was followed up until the delivery of a healthy baby boy and did not experience an episode of acute pancreatitis. ConclusionsWith adequate supervision and monitoring therapeutic plasma exchange represents a safe approach in pregnant women with FCS in order to reduce TGs and prevent pancreatitis. Therefore, we prevented potential complications for both mother and child.

UTILIZATION OF POINT-OF-CARE ULTRASOUND AND ROTATIONAL THROMBOELASTOMETRY TO DIAGNOSE AND MANAGE AMNIOTIC FLUID EMBOLISM PRESENTING AS POST-PARTUM HEMORRHAGE AND CARDIAC ARREST

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Amniotic fluid embolism (AFE) is a life-threatening obstetrical emergency. Despite its clinical significance there is little guidance on diagnosis and management[1, 2, 3]. In the absence of more specific diagnostic guidelines, point-of-care ultrasound (POCUS) in combination with rotational thromboelastometry (ROTEM) can aid in the diagnosis and management of AFE and have a significant impact on clinical outcomes[4]. CASE PRESENTATION: A 29-year-old, previously healthy, gravida 1 female presented at 39 weeks' gestation for induction of labor due to gestational diabetes and concerns surrounding the COVID-19 pandemic. The patient was laboring for approximately 10 hours when she suddenly started to feel nauseous, lightheaded, and subsequently suffered a syncopal episode complicated by fetal bradycardia. She was tachycardic, poorly responsive and in respiratory distress. She was transferred to the operating room (OR) for emergency Cesarean section. After the uterine incision, the intubated patient developed circulatory collapse followed by a sinus tachycardia pulseless electrical activity (PEA) arrest. Chest compressions were initiated, and the hospital code/resuscitation team was called to the OR. The patient started bleeding from her incision leading to an initial diagnosis of hemorrhagic shock. The code team, equipped with point-of-care ultrasound skill obtained an apical 4-chamber view (Figure 1) that revealed a severely dilated and hypokinetic right ventricle, and a hyperdynamic, underfilled left ventricle. The ultrasound findings in combination with significant bleeding were felt to be consistent with AFE not hemorrhagic shock and the extracorporeal membrane oxygenation (ECMO) team was activated for bedside cannulation. ROTEM (Figure 2) demonstrated markedly prolonged clotting time, prolonged clotting formation time and very low clot amplitude consistent with DIC, further supporting the diagnosis of AFE and prompted the difficult decision to withhold heparin after VA-ECMO cannulation. Following stabilization, patient was transferred to the intensive care unit with a diagnosis of AFE complicated by DIC and post-partum hemorrhage. She left the hospital with no physical or neurologic deficits 31 days later with her healthy baby boy. DISCUSSION: The description of POCUS use during cardiovascular resuscitation in the setting of AFE and other obstetric emergencies is rare. Identifying a dilated right ventricle on ultrasound can narrow the diagnosis of circulatory collapse in the peripartum patient to pulmonary embolism (PE) and AFE. ROTEM can help differentiate AFE from PE by identifying DIC with one study estimating the occurrence of DIC in PE at 1 % compared to 30-77% in AFE[5]. CONCLUSIONS: The use of POCUS and ROTEM in the diagnosis and management of AFE can guide lifesaving clinical decision making in the peripartum patient who develops circulatory collapse followed by cardiac arrest. REFERENCE #1: Sitaula S, Das D, Sitaula S, Chhetry M. Amniotic fluid embolism: A rare cause of maternal collapse-A case report. Clin Case Rep. 2020;8(12):3359-3361. Published 2020 Oct 26. doi:10.1002/ccr3.3433 REFERENCE #2: Loughran JA, Kitchen TL, Sindhakar S, Ashraf M, Awad M, Kealaher EJ. Rotational thermoelectrometry (ROTEM®)-guided diagnosis and management of amniotic fluid embolism. Int J Obstet Anesth. 2019;38:127-130. doi:10.1016/j.ijoa.2018.09.001 REFERENCE #3: Rath WH, Hoferr S, Sinicina I. Amniotic fluid embolism: an interdisciplinary challenge: epidemiology, diagnosis and treatment. Dtsch Arztebl Int. 2014;111(8):126-132. doi:10.3238/arztebl.2014.0126 DISCLOSURES: No relevant relationships by Angela Phillips, source=Web Response No relevant relationships by David Tierney, source=Web Response

Androgen Secreting Adenoma Co- Secreting Cortisol First Diagnosed During Pregnancy

Background: Pure androgen secreting adenoma is rare (1) and rarer to have an adenoma that is co-secreting androgen and cortisol, and extremely rare to have it diagnosed during pregnancy. In female, an elevated serum testosterone level with normal adrenal androgens is usually regarded as ovary origin (2). Here we report an unusual case of pregnant woman with markedly elevated serum testosterone level and elevated cortisol that first presented during pregnancy. Clinical Case: A 32-year old lady who is 32 weeks pregnant, presented with signs and symptoms of Cushing and acute hirsutism developed and advanced during pregnancy. Clinically She had hypertension, gestational diabetes with sever hirsutism and virilization. Fasting total testosterone was high (52 nmoL/L n 0.2–2.9 nmoL/L), DHEAS (1.98 umol/L n 0.51–11 umol), 24 hours urine cortisol (1343 nmoL/24 hrs n 11.8–485 nmoL/24 hrs), ACTH (0.220 pmol/L n 1.6–13.9pmol/L). Adrenal MRI without contrast showed a large right adrenal mass of 6.5 x 6.2 x 5.3 cm, of heterogenous signal in all pulse sequences, with limited assessment due to the lack of IV contrast. During admission,the patient’s liver enzymes were gradually increasing which lead to the decision of an elective C-section at 34 weeks gestation followed by right robotic adrenalectomy after ruling out pheochromocytoma. The product was viable and healthy baby boy. The immediate post-op hormonal profile showed normalization of urinary cortisol and serum total testosterone level. Histopathology report confirmed an Adrenocortical adenoma. The patient was discharged on the 3rd day post-op on hydrocortisone replacement therapy. The hydrocortisone doses were gradually tapered down tell stopped. The course of follow up was uneventful, two years following the surgery, she got another pregnancy with no obvious complications.Conclusion: Co- existing testosterone and cortisol secreting adrenocortical adenoma is a rare tumor, diagnosis and management during pregnancy is challenging, with surgical resection being the only possible definite management.