Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

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Adult Granulosa Cell and Thecoma/Fibrothecoma Tumor of the Ovary in Pregnancy Ogrodnik, K, MSIII; Cal, N, MSIII. Eastern Connecticut Health Network, Manchester Memorial Hospital, Obstetrics & Gynecology, Manchester, CT. Introduction: The occurrence of ovarian tumors diagnosed during pregnancy is rare, with an estimated incidence of 0.11 per 1000 pregnancies. About 10% of granulosa cell tumors (GCT), a type of sex cordstromal tumor of the ovary, present in pregnancy. GCT is a very rare form of neoplasm that has the tendency to be malignant. It can present as a large mass with a mean diameter of 15 cm and it can be hormonally active. The adult granulosa cell tumors (AGCTs) account for 1-2% of all ovarian tumors and their occurrence is most frequently observed in peri- and postmenopausal women. This case describes an unusual type of ovarian tumor in a young pregnant woman. Our case is rare because of the patient’s childbearing age, a rapidly enlarging mass which persisted into the third trimester of pregnancy and the simultaneous incidence of two types of sex cord-stromal tumors: adult granulosa cell tumor and thecoma/ fibrothecoma. Case: A 30-year-old Caucasian female, G1P2 presented at 30 weeks gestation. She had an unremarkable prenatal course until week 20 during which her routine ultrasound revealed the presence of a right ovarian mass measuring approximately 6 cm in diameter. The mass was asymptomatic, believed to most likely be a cyst and it was decided that the mass would be closely monitored throughout the pregnancy. At 28 weeks, patient began to experience mild and intermittent pelvic pain. By the 30 th week, the pain began to intensify, becoming extremely sharp and constant. At 36 weeks, right pelvic pain suddenly worsened. At 36 weeks and 4 days, it was discovered that the mass was now measuring 17 cm in diameter, resulting in a growth of 11 cm in a period of 10 weeks. An amniocentesis was performed to assess for fetal lung maturity and to evaluate for the possibility of an immediate delivery. Following the amniocentesis, patient developed an acute and intolerable right lower quadrant pain. Fortunately, fetal heart rate remained adequate and reassuring. Despite amniocentesis results confirming immature fetal lungs, it was decided that an elective cesarean delivery would be performed, followed by a right oophorectomy. A viable 3,160 g female fetus was successfully delivered with APGAR scores of 9 and 9. Caesarian section proceeded without complications and without excessive blood loss. Discussion: Few cases of adult granulosa cell tumors or thecoma/fibrothecoma in pregnancy have been described in the literature. There appears to be no recent cases of pregnant women with a combination of a granulosa cell tumor and of a thecoma/fibrothecoma as observed in our patient. Our case presents a gravid patient with an uncommon case of an adult type of granulosa cell tumor of the ovary and of a concurrent ovarian thecoma/fibrothecoma. Patient displayed no apparent risk factors for such tumors, there was no report of a family history of breast or ovarian cancer or a state of nulliparity as patient had previously delivered a viable female fetus. Another unusual feature is the presentation of these tumors at a child bearing age. Most sex-cord stromal tumors occur beyond our patient’s young age of 30. In addition, most adnexal masses, as mentioned previously, do not persist beyond the first trimester and usually resolve spontaneously. In such cases, the only management is a close monitoring of the pregnancy. Our patient’s mass persisted into the third trimester and grew rapidly. Therefore, there was a high risk of malignancy and ensuing complications. Ovarian tumors, if hormonally active, can cause various clinical problems. They can produce any of the sex steroid hormones. The pathologic secretion of these estrogenic or androgenic hormones can lead to specific effects on hormone-sensitive organs. In addition to the endocrine effects, ovarian tumors can cause additional complications due to their mass effect. Adnexal masses that persist into the second trimester of pregnancy, as occurred in our patient, are at a greater risk for torsion, which is found to occur in 15-20 % of ovarian tumor cases. Ovarian torsions increase the incidence of spontaneous miscarriage or preterm delivery and can also lead to obstruction of labor. It is clear that routine use of ultrasound in early pregnancy has increased the incidence and detection rate of ovarian masses in pregnancy. Although most masses are found to be cysts of benign entities, it is important to monitor the pregnancy closely as the mass could progress and potentially be malignant. Earlier detection and suspicion of a tumor can aid the obstetric team in efficiently managing the pregnancy and monitoring for any signs of ovarian torsion, rupture or obstruction which could compromise the pregnancy.
Uterine Perforation in a 36 Year Old Female Petrone, G,OMSIII; Salk,R, DO University of New England College of Osteopathic Medicine, Biddeford ME Introduction: The prevalence of uterine anomalies is higher among women with adverse reproductive outcomes such as recurrent pregnancy losses, infertility, malpresentation, preterm birth, and premature rupture of membranes. Our patient, with a known uterine didelphys, underwent dilation and curettage after suffering a second first trimester miscarriage. During the procedure both uteri were believed to have been perforated. Case: A 36 year old female, gravida 2, para 0 with known history of previous early trimester loss, currently undergoing fertility treatment is referred for dilation and curettage following missed abortion. Ultrasound revealed a nonviable fetus, 7 week 5 day gestation in the left horn. Patient was brought to the operating room and received general anesthesia. On examination there was noted to be a mid vaginal septum extending to the apex of the vagina as well as a bilateral cervix and uterine didelphys with enlarged left uterus. The cervix was dilated and on initial suction curettage revealed no tissue. With further instrumentation there was noted to be no significant tissue or bleeding. The right side uterine cervix was dilated. With free passage of the dilator there was felt to be perforation. On re-inspection of the left uterus with ultrasound the cavity was unable to be cannulated with perforation extending medially and a thin myometrium of less than 0.5cm on the medial aspect. After suspected perforation pelviscopy evaluation was performed. Upon inspection there was noted to be 30-40 cc of blood in the cul-de-sac on both sides of the septum. The right uterus revealed a pinpoint perforation on the medial aspect which was cauterized. Evaluation of the left horn revealed a perforation on the medial aspect with thin myometrium. The margins of the myometrium were cauterized. The pelvis was irrigated. Due to the extent of laceration and hemostasis it was felt to be best to review further treatment options with the patient prior to proceeding with any further surgical treatment. Discussion: Uterine perforation is a potential complication of several intrauterine procedures, as well as, the most immediate complication of dilation and curettage. The risk of perforation is increased by factors that limit access to the uterine cavity or decrease the strength of the myometrium. Such factors include cervical stenosis, scarring of the endocervical canal due to cone biopsy, uterine malposition, distortion of the uterine anatomy, menopause and pregnancy. Uterine perforation is associated with multiple complications. Short term risks include hemorrhage and injury to bowel or bladder. Long term risks include sepsis due to an unrecognized bowel perforation or a bladder perforation leading to either a rectal vaginal fistula or a bladder vaginal fistula due again to unrecognized injury at the time of perforation. In conclusion when a perforation is suspected a diagnostic laparoscopy is warranted in order to diagnose and treat an injury to the vasculature, bladder and or bowel, to prevent hemorrhage, sepsis and resultant fistulas.
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Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

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