Rare Complication Of Pregnancy Research Articles

Acquired hemophilia A manifesting as plasma transfusion‐uncontrolled severe bleeding 2 weeks after chorioamnionitis‐induced abortion

Acquired hemophilia A (AHA) is a serious and rare complication of pregnancy, caused by autoantibodies to coagulation factor VIII after delivery. We here report the case of a 36-year-old primigravida woman who developed AHA following chorioamnionitis-caused miscarriage in the second trimester. Thirteen days after abortion, sudden, massive vaginal bleeding occurred with marked prolongation of activated partial thromboplastin time (APTT) in the absence of other abnormal coagulation data. Sequential transfusion of fresh frozen plasma did not achieve normalization of APTT. Further examination confirmed reduction of coagulation factor VIII and the presence of its inhibitor, leading to the final diagnosis of AHA. The patient was effectively treated with bypassing agents (activated prothrombin complex concentrate and recombinant activated factor VII) and immunosuppressive therapy. Fifteen months after remission, the patient became pregnant and successfully achieved term delivery with no signs of recurrence. This case illustrates that AHA should be considered in the occurrence of plasma transfusion-uncontrolled severe bleeding after delivery.

Using Radio-Frequency Ablation Electrode in Effective Treatment of Hepatic Rupture in HELLP Syndrome. Case Report and Review of the Literature

Spontaneous hepatic rupture constitutes very rare complication of pregnancy and is associated with an increased risk of mortality. The patient presented at 30 weeks of gestation with HELLP syndrome developed life threatening hepatic rupture. She underwent an emergent cesarean delivery followed by exploration of her abdomen by hepatobiliary surgeons. An expanding hematoma with rupture of the right and left lobe of the liver was successfully treated with radiofrequency ablation electrode. The patient was discharged home in good condition 13 days after surgery. Quick diagnosis, multidisciplinary approach and radio-frequency ablation help to achieve an excellent clinical outcome in a patient with hepatic rupture from HELLP syndrome.

P.2.h.008 - Prevalence of depression in primary care settings in Latvia – the results of the National Research Program BIOMEDICINE

Abnormally invasive placenta (AIP) is a rare pregnancy complication often resulting in postpartum haemorrhage (PPH) and emergency peripartum hysterectomy (EPH). The risk of developing post traumatic stress disorder (PTSD) following unexpectedly traumatic childbirth is known however there is no evidence regarding PTSD in AIP. This pilot study assesses the risk of PTSD for women with AIP compared to women having an uncomplicated caesarean delivery (CD) or unexpected PPH or EPH.Retrospective case-controlled questionnaire study in a UK Tertiary obstetric unit. Women with AIP (Group-1) were matched by delivery date to control groups: Group-2, women with an uncomplicated CD; Group-3 women referred to a specialist clinic for suspected AIP, but had a normal placenta and uncomplicated CD; Group-4, women who had an unexpected EPH and/or severe (>3000 mls) PPH. 218 women were sent a validated PTSD screening questionnaire (Impacts of Events Scale-Revised [IES-R]).Likelihood of PTSD was recorded for 69 women who responded, revealing significantly higher PTSD scores for women with AIP compared to uncomplicated CD (P = 0.001). No significant difference was seen between AIP and EPH/PPH (P = 0.89). The number of women with scores high enough to indicate probable PTSD was significantly greater with AIP than uncomplicated CD group (P = 0.045).This study demonstrates that women antenatally diagnosed with AIP and anticipating a potentially traumatic delivery, are at significantly increased risk of developing PTSD. Improved awareness of the negative psychological impact of AIP may increase the number of women being identified and treated, thereby improving their quality of life.

Epidemiology of hypertensive disorders in pregnancy: prevalence, risk factors, predictors and prognosis

Hypertensive disorders in pregnancy (HDP) represent some of the most important problems faced by public health because HDP is a major cause of maternal and prenatal morbidity and mortality. Several epidemiological studies have been performed to determine the prevalence and risk factors of HDP as well as its subtypes. The prevalences of HDP, gestational hypertension and preeclampsia are 5.2-8.2%, 1.8-4.4% and 0.2-9.2%, respectively. Body mass index, anemia and lower education appear to be modifiable risk factors for HDP. Maternal age, primiparous, multiple pregnancy, HDP in previous pregnancy, gestational diabetes mellitus, preexisting hypertension, preexisting type 2 diabetes mellitus, preexisting urinary tract infection and a family history of hypertension, type 2 diabetes mellitus and preeclampsia appear to be nonmodifiable risk factors. Genetic variants including a single-nucleotide polymorphism in the angiotensinogen gene have also been reported to be nonmodifiable risk factors. Epidemiological studies have recently examined the associations between a history of HDP and its subtypes and future risks of other diseases. These studies have reported associations between a history of HDP and a risk of coronary heart disease, heart failure, dysrhythmia, stroke, hypertension, diabetes mellitus, end-stage renal dysfunction and cardiomyopathy. HDP is not associated with the future incidence of total cancer. In conclusion, HDP is not a rare complication of pregnancy and the influence of HDP remains for an extended duration. Physicians should consider the effects of HDP when treating chronic diseases in women.

The Value of Ultrasonography in Predicting Invasive Mole

Background: Gestational trophoblastic neoplasm (GTN) during pregnancy includes an associated heterogeneous group of lesions that originates from abnormal proliferation of placenta. It includes invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. Objectives: The aim of this study was to predict the risk of invasive mole in patients with a molar pregnancy in association with -hCG level after the evacuation of molar pregnancy. Methods: The current study was a prospective cross-sectional cohort research conducted as a diagnostic study on 110 patients with molar pregnancy referring to Department of Gynecology and Oncology of Vali-Asr, Imam Khomeini Hospital of Tehran between the years of 2015 and 2016. Patients with molar pregnancy, who were hospitalized with a diagnosis of hydatidiform mole by transvagi- nal ultrasonography, were examined in the study. The ability to perform ultrasonography before and after evacuation as well as the consent to participate in the study was among the inclusion criteria for patients. The patients were studied for invasive mole fol- lowed by two ultrasonography examinations, one 48 hours and the other 21 days after evacuation. -hCG levels were also measured in successive periods of one week to six months. The association of sonography findings 48 hours and 21 days after evacuation with post-evacuation -hCG levels was investigated using Chi-square test and multinomial regression. Results: In the current study conducted on 110 patients with hydatidiform mole, the results showed that 46 patients (41.8%) suered from invasive mole. In 23 patients (50%) with invasive mole, the results of both ultrasonography 48 hours and 21 days after evacuation were positive. There was a significant correlation between ultrasonography after evacuation (positive and negative results) and the progress of -hCG after evacuation in women with invasive mole (P = 0.001); this means that in 73% of women with invasive mole, the positive -hCG results corresponded with positive 21-day sonography after evacuation, and in 41% cases, ultrasound results on day 21 were reported positive before the results of -hCG. Conclusions: Positive results of sonography accompanied with positive results of -hCG have a high eciency in the diagnosis of 1. Background Gestational trophoblastic disease (GTD) includes a het- erogeneous group of related lesions resulted from abnor- mal proliferation of placenta. GTD may be either benign or malignant. Benign lesion includes complete and par- tial hydatidiform mole and its diagnosis is based on histo- logical findings. Malignant lesion includes invasive mole, placental site trophoblastic tumors, and choriocarcinoma. Trophoblastic disease during pregnancy has the potential for local invasion and distant metastasis. This group of ma- lignant lesions is called gestational trophoblastic neopla- sia (GTN), which is a rare complication of pregnancy. GTN, occurs after normal delivery, spontaneous abortion or ec- topic pregnancy. The risk of its occurrence increases by 2,000 times after the occurrence of hydatidiform mole (1-

Diabetes insipidus and pregnancy

Diabetes insipidus (DI) is a rare complication of pregnancy. It is usually transient, being due to increased placental production of vasopressinase that inactivates circulating vasopressin. Gestational, transient DI occurs late in pregnancy and disappears few days after delivery. Acquired central DI can also occur during pregnancy, for example in a patient with hypophysitis or neuroinfundibulitis during late pregnancy or postpartum. Finally, pre-existing central or nephrogenic DI may occasionally be unmasked by pregnancy. Treatment with dDAVP (desmopressin, Minirin®) is very effective on transient DI of pregnancy and also on pre-existing or acquired central DI. Contrary to vasopressin, dDAVP is not degraded by vasopressinase. Nephrogenic DI is insensitive to dDAVP and is therefore more difficult to treat during pregnancy if fluid intake needs to be restricted.

CORONARY ARTERY DISSECTION IN EHLERS DANLOS SYNDROME

Coronary artery dissection is a rare complication of pregnancy. The underlying causes of the disorder remain vastly unknown. An association with collagen vascular disease has been described. A 42 year old woman presented to the emergency department with resting angina two weeks post delivery via

Peripartum Cardiomyopathy (PPCM): Dual Case Report and Review of Literatures

Introduction:Peripartum cardiomyopathy (PPCM), unexplained heart failure is a rare complication of pregnancy that occurs at the end of pregnancy or early during the postpartum period. PPCM is a diagnosis of exclusion that is made after other possible etiologies have been eliminated. The presentation of PPCM is generally during the early postpartum period where the patient will typically present with heart failure symptoms; these symptoms are often mistaken for being part of the normal puerperal experience. Although there are many risk factors for the development of PPCM, the greatest risk factors include being of African descent, having multiple gestation pregnancies and advanced maternal age. The etiology of PPCM has never been completely understood. However, it has been postulated that it is related to persistent viral antigen exposure. The management guidelines of the patient with PPCM generally follow guidelines for the management of congestive heart failure resulting from other etiologies, with the exception that angiotensin-converting-enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs), contraindicated during pregnancy, because of their teratogenic effects. Case description:We present two cases of peripartum cardiomyopathy (PPCM) with the discussion of management and literature review. Conclusion:Although the prognosis of PPCM is usually favorable, maternal mortality has been reported. Therefore, clinicians must remain vigilant to facilitate timely recognition of the peripartum complication. Serious nonfatal complications including cardiacdysrhythmias, progressive heart failure requiring heart transplantation, and thromboembolic events manifesting as cerebral vascular accidents and peripheral arterial embolism may occur. Early diagnosis and prompt treatment is associated with a decrease in morbidity and mortality associated with PPCM.

Successful management of diverse types of heterotopic pregnancies

Heterotopic pregnancy is a rare complication of pregnancy. It can be a life threatening condition and can be easily missed if the diagnosis is overlooked. There is an increase in cases of heterotopic pregnancy in the last decade due to an increase in the incidence of pelvic inflammatory disease, tubal surgeries, pharmacologic ovulation stimulation, and assisted reproductive techniques. A timely diagnosis and intervention can save the life of the patient as well as the intrauterine pregnancy, which can be continued for a successful outcome. Here, we present three cases of heterotopic pregnancy that presented to our hospital over a period of 6 years with different clinical presentations who were treated with successful outcome.

A Case of Intestinal Obstruction in Pregnancy Diagnosed by MRI and Treated by Intravenous Hyperalimentation.

Intestinal obstruction in pregnancy is rare and is mainly caused by prior pelvic surgery. We herein report a case of intestinal obstruction in a pregnant female with a history of laparoscopic myomectomy, who presented with hypogastric pain, abdominal distension, and vomiting at 26 weeks of gestation. A simple intestinal obstruction was diagnosed by MRI. Conservative treatments, including intravenous hyperalimentation and the placement of an ileus tube, were provided and her abdominal symptoms improved for 14 days. After restarting oral intake, she had no abdominal symptoms. She gave birth to a 2,146 g female infant by caesarean section at 37 weeks and 1 day of gestation. Although an area of cicatrization, which was thought to have been the starting point of the occlusion that caused the intestinal obstruction, was found, the excision of the small intestine was not necessary. Her postoperative course was uneventful. Intestinal obstruction requires a prompt diagnosis and aggressive intervention may be necessary to minimize the morbidity and mortality associated with this rare complication of pregnancy. MRI can be safely used during pregnancy to diagnose intestinal obstruction and intravenous hyperalimentation may improve the maternal and fetal prognoses.

Wernicke&'s encephalopathy in hyperemesis gravidorum

Wernicke&'s encephalopathy (WE) is potentially a fatal complication due to the deficiency of vitamin B1 and presents with a neurological triad of nystagmus, encephalopathy, and ataxia. It is most commonly seen in alcoholics and is a rare complication of pregnancy associated with hyperemesis gravidorum (HG). Since it is a rare condition, difficult to diagnose in pregnancy, and can prove to be fatal, a high index of suspicion should be made in case of pregnancy complicated by HG. We hereby report a case of WE caused by HG successfully treated with a high dose intravenous thiamine. This case is the first of its kind from our part of world.

Transient diabetes insipidus in pregnancy.

SummaryGestational diabetes insipidus (DI) is a rare complication of pregnancy, usually developing in the third trimester and remitting spontaneously 4–6 weeks post-partum. It is mainly caused by excessive vasopressinase activity, an enzyme expressed by placental trophoblasts which metabolises arginine vasopressin (AVP). Its diagnosis is challenging, and the treatment requires desmopressin. A 38-year-old Chinese woman was referred in the 37th week of her first single-gestation due to polyuria, nocturia and polydipsia. She was known to have gestational diabetes mellitus diagnosed in the second trimester, well-controlled with diet. Her medical history was unremarkable. Physical examination demonstrated decreased skin turgor; her blood pressure was 102/63 mmHg, heart rate 78 beats/min and weight 53 kg (BMI 22.6 kg/m2). Laboratory data revealed low urine osmolality 89 mOsmol/kg (350–1000), serum osmolality 293 mOsmol/kg (278–295), serum sodium 144 mmol/l (135–145), potassium 4.1 mmol/l (3.5–5.0), urea 2.2 mmol/l (2.5–6.7), glucose 3.5 mmol/l and HbA1c 5.3%. Bilirubin, alanine transaminase, alkaline phosphatase and full blood count were normal. The patient was started on desmopressin with improvement in her symptoms, and normalisation of serum and urine osmolality (280 and 310 mOsmol/kg respectively). A fetus was delivered at the 39th week without major problems. After delivery, desmopressin was stopped and she had no further evidence of polyuria, polydipsia or nocturia. Her sodium, serum/urine osmolality at 12-weeks post-partum were normal. A pituitary magnetic resonance imaging (MRI) revealed the neurohypophyseal T1-bright spot situated ectopically, with a normal adenohypophysis and infundibulum. She remains clinically well, currently breastfeeding, and off all medication. This case illustrates some challenges in the diagnosis and management of transient gestational DI.Learning pointsGestational DI is a rare complication of pregnancy occurring in two to four out of 100 000 pregnancies. It usually develops at the end of the second or third trimester of pregnancy and remits spontaneously 4–6 weeks after delivery.Gestational DI occurrence is related to excessive vasopressinase activity, an enzyme expressed by placental trophoblasts during pregnancy, which metabolises AVP. Its activity is proportional to the placental weight, explaining the higher vasopressinase activity in third trimester or in multiple pregnancies.Vasopressinase is metabolised by the liver, which most likely explains its higher concentrations in pregnant women with hepatic dysfunction, such acute fatty liver of pregnancy, HELLP syndrome, hepatitis and cirrhosis. Therefore, it is important to assess liver function in patients with gestational DI, and to be aware of the risk of DI in pregnant women with liver disease.Serum and urine osmolality are essential for the diagnosis, but other tests such as serum sodium, glucose, urea, creatinine, liver function may be informative. The water deprivation test is normally not recommended during pregnancy because it may lead to significant dehydration, but a pituitary MRI should be performed at some point to exclude lesions in the hypothalamo-pituitary region.These patients should be monitored for vital signs, fluid balance, body weight, fetal status, renal and liver function, and treated with desmopressin. The recommended doses are similar or slightly higher than those recommended for central DI in non-pregnant women, and should be titrated individually.

Mirror Syndrome: A Reflection of Fetal Health

Background Mirror syndrome was first described as a clinical occurrence in 1892 by John Ballantyne in which nonimmune hydrops fetalis complicates the pregnancy. Maternal edema and other complications including preeclampsia mirror the hydrops noted in the fetus. The purpose of this case presentation is to familiarize the perinatal nurse with this rare complication of pregnancy and to describe the ethical dilemma of immediate delivery versus postponing delivery due to extreme prematurity. Case Three weeks after the diagnosis of nonimmune hydrops fetalis secondary to a large sacrococcygeal tumor, the woman at 24 weeks 5 days gestation presented with severe bilateral lower extremity edema. On admission the woman was noted to have severe range blood pressures, proteinuria, and epigastric pain. Laboratory data also revealed elevated liver enzymes, severe anemia with hemoglobin of 5.0 and hematocrit of 15.3, and thrombocytopenia. Ultrasound and magnetic resonance imaging (MRI) studies revealed worsening nonimmune hydrops fetalis and a significant increase in the size of the sacrococcygeal tumor rivaling the size of the fetus. The woman was immediately started on mjagnesium sulfate, labetalol, betamethasone, and blood replacement products. Several consults were performed with neonatology, pediatric surgery, hematology, and maternal/fetal medicine. The maternal/fetal medicine team assumed care of the woman and encouraged immediate delivery. The woman and her family wanted to continue the pregnancy until 28 weeks to allow for additional maturity of the fetus. Discussions ensued outlining the risks for the mother and to the fetus of continuing the pregnancy. Conclusion At this point the mother continued to refuse delivery. An ethicist was called in to assist and described the four fundamental principles of ethics, beneficence, autonomy, nonmaleficence, and justice, and their relationship to this case. After 2 days of hospitalization the woman relented and a cesarean was performed. The mother needed additional blood products but was discharged to home after 6 days. The newborn underwent emergency surgery to remove the tumor, however, she succumbed to heart failure during the postoperative period. Mirror syndrome was first described as a clinical occurrence in 1892 by John Ballantyne in which nonimmune hydrops fetalis complicates the pregnancy. Maternal edema and other complications including preeclampsia mirror the hydrops noted in the fetus. The purpose of this case presentation is to familiarize the perinatal nurse with this rare complication of pregnancy and to describe the ethical dilemma of immediate delivery versus postponing delivery due to extreme prematurity. Three weeks after the diagnosis of nonimmune hydrops fetalis secondary to a large sacrococcygeal tumor, the woman at 24 weeks 5 days gestation presented with severe bilateral lower extremity edema. On admission the woman was noted to have severe range blood pressures, proteinuria, and epigastric pain. Laboratory data also revealed elevated liver enzymes, severe anemia with hemoglobin of 5.0 and hematocrit of 15.3, and thrombocytopenia. Ultrasound and magnetic resonance imaging (MRI) studies revealed worsening nonimmune hydrops fetalis and a significant increase in the size of the sacrococcygeal tumor rivaling the size of the fetus. The woman was immediately started on mjagnesium sulfate, labetalol, betamethasone, and blood replacement products. Several consults were performed with neonatology, pediatric surgery, hematology, and maternal/fetal medicine. The maternal/fetal medicine team assumed care of the woman and encouraged immediate delivery. The woman and her family wanted to continue the pregnancy until 28 weeks to allow for additional maturity of the fetus. Discussions ensued outlining the risks for the mother and to the fetus of continuing the pregnancy. At this point the mother continued to refuse delivery. An ethicist was called in to assist and described the four fundamental principles of ethics, beneficence, autonomy, nonmaleficence, and justice, and their relationship to this case. After 2 days of hospitalization the woman relented and a cesarean was performed. The mother needed additional blood products but was discharged to home after 6 days. The newborn underwent emergency surgery to remove the tumor, however, she succumbed to heart failure during the postoperative period.

Characteristics and Outcomes of AKI Treated with Dialysis during Pregnancy and the Postpartum Period.

Acute kidney injury (AKI) is a rare complication of pregnancy, but may be associated with significant morbidity and mortality in young and often otherwise healthy women. We conducted a retrospective population-based cohort study of all consecutive pregnancies over a 15-year period (1997-2011) in Ontario, Canada, and describe the incidence and outcomes of AKI treated with dialysis during pregnancy or within 12 weeks of delivery. Of 1,918,789 pregnancies, 188 were complicated by AKI treated with dialysis (incidence: 1 per 10,000 [95% confidence interval, 0.8 to 1.1]). Only 21 of 188 (11.2%) women had record of a preexisting medical condition; however, 130 (69.2%) women experienced a major pregnancy-related complication, including preeclampsia, thrombotic microangiopathy, heart failure, sepsis, or postpartum hemorrhage. Eight women died (4.3% versus 0.01% in the general population), and seven (3.9%) women remained dialysis dependent 4 months after delivery. Low birth weight (<2500 g), small for gestational age, or preterm birth (<37 weeks' gestation) were more common in pregnancies in which dialysis was initiated (35.6% versus 14.0%; relative risk, 3.40; 95% confidence interval, 2.52 to 4.58). There were no stillbirths and fewer than five neonatal deaths (<2.7%) in affected pregnancies compared with 0.1% and 0.8%, respectively, in the general population. In conclusion, AKI treated with dialysis during pregnancy is rare and typically occurs in healthy women who acquire a major pregnancy-related medical condition such as preeclampsia. Many affected women and their babies have good short-term outcomes.

Endocarditis infecciosa de la válvula mitral en gestante

Infective endocarditis is a rare complication of pregnancy with high maternal and fetal mortality. We report the case of a 26-year-old woman with acute bacterial endocarditis of a rheumatic mitral valve in the 28th week of pregnancy. Echocardiography revealed a mobile vegetation of 20 mm length on the posterior leaflet of the mitral valve with subsequent severe mitral regurgitation. The patient responded favorably to a 5-week course of antibiotic therapy, and there were no signs of fetal repercussions. As an intercurrent complication, she was diagnosed with a mycotic aneurism of the femoral artery in the 33rd week of pregnancy. Antenatal corticosteroids for fetal lung maturation were administered, followed by surgery. This case illustrates the importance of a multidisciplinary approach, which, in our patient, allowed term delivery with favorable maternal and fetal outcomes.

Managing cesarean section in a patient with rotated uterus due to a large myoma.

Key Clinical MessageIn pregnancies complicated by large myomas, obstetricians may face difficulties during cesarean section if they fail to notice the rotation of the uterus and could make an incorrect uterine incision. This error might cause massive intraoperative hemorrhage. Obstetricians must exercise extreme caution during cesarean sections complicated by large myomas.

Hypertriglyceridemia-induced acute pancreatitis in pregnancy.

Hypertriglyceridemia is a well known phenomenon of pregnancy occurring due to physiologic changes in sex hormone levels. Occasionally, it could lead to development of acute pancreatitis. Gestational hypertriglyceridemia-induced acute pancreatitis occurs in pregnant women usually with preexisting abnormalities of the lipid metabolism and is associated with additional diagnostic and therapeutic challenges related to hypertriglyceridemia and pregnancy. We present a case of the hypertriglyceridemia-induced acute pancreatitis in pregnant woman with no previous history of lipid abnormality and pregnancy as the only known triggering factor for hypertriglyceridemia. Hypertriglyceridemia-induced acute pancreatitis is a rare complication of pregnancy; however, it should be suspected in all pregnant patients admitted for nonobsteric abdominal pain.

Conservative management of placenta percreta: a case report

Morbidly adherent placenta is a rare complication of pregnancy associated with high maternal morbidity. It may cause massive haemorrhage thereby requiring emergency hysterectomy. We present a case of placenta percreta which was manged succesfully by conservative management.

English

Torsion of gravid uterus is a rare complication in pregnancy. It is often associated with a previous cesarean section. When a patient with a previous history of ceasarean section complains of pain abdomen, apart from scar dehiscence and abruptio placenta, torsion of gravid uterus should be entertained as a differential diagnosis. The case report highlights the presentation of rare case of torsion of gravid uterus.

Uterine Rupture After Uterine Artery Embolization for Symptomatic Leiomyomas

There are few data regarding safety of pregnancy after uterine artery embolization. However, numerous women desire future fertility after this procedure. Uterine rupture without a history of cesarean delivery or uterine scarring is an exceedingly rare complication in pregnancy. We report a case of uterine rupture in a primigravid woman after uterine artery embolization. Her pregnancy was also complicated by placenta previa with placenta increta, resulting in a favorable neonatal outcome in an otherwise life-threatening situation for mother and fetus. Uterine artery embolization is a risk factor for abnormal placentation and uterine rupture in subsequent pregnancies.