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The present case study reports about Placental mesenchymal dysplasia co-existing with high grade villitis of unknown aetiology (VUE). Placental Mesenchymal Dysplasia (PMD) is a rare placental lesion characterized by unusual abnormality of the stem villi of the placenta that could be mistaken for hydatidiform mole due to the presence of both cysts and normal-appearing parenchyma. A 30-year-old G2 P1 (full-term normal delivery) seen in fetal medicine clinic at 20 weeks within view of high risk on combined screening (low PAPP-A and high HCG). An ultrasound scan showed an appropriately grown baby with an abnormal placenta consisting of multiple lacunae more than 50% of the placental mass with increased thickness. A second opinion at tertiary care hospital confirmed the presence of prominent lakes on the placenta. Growth scans also showed IUGR with increasingly abnormal Doppler scans as the pregnancy progressed. At 35 weeks, EFW was < 3rd centile with static growth and patient had Induction of labour at 35 +4 weeks with vaginal delivery of a live male neonate weighing 2325g admitted to the neonatal intensive care unit (NICU) admission due to prematurity. The baby was discharged from NICU at day 5, achieving developmental milestones at the age of 23 weeks post-delivery. On microscopic histological examination, the chorionic plate showed no significant abnormality. The villous architecture was highly abnormal, and some villi were markedly enlarged with myxoid stroma and central degeneration. There were very occasional foci of apparent trophoblastic proliferation with villous architecture abnormalities seen in the form of clusters of large, immature intermediate villi. These features were in keeping with mesenchymal dysplasia. A highly unusual finding in this context was a florid infiltrate of CD3 positive T cells consistent with high-grade villitis of unknown aetiology concluding very rare co-existence of both conditions.

Salmonella is an extremely rare cause of an infected endometrioma. We present a case of a 30-year-old immunocompetent woman presenting with fevers and abdominal pain, on a background of prior endometriosis. Initial antibiotic treatment for pelvic inflammatory disease failed, and the patient progressed to septic shock requiring surgical evacuation of an infected ovarian endometrioma. Microbiological samples from stool, ovary, and peritoneal fluid revealed infection withSalmonella senftenberg. The likely diagnosis was Salmonella enterocolitis with bacterial translocation to an ovarian endometrioma.

Spontaneous haemoperitoneum in pregnancy (SHiP) due to endometriosis is a very rare condition and this is a case of a 41-year-old primigravida, who presented at 32 weeks with sudden onset of severe lower abdominal pain without any uterine activity. This was a dichorionic-diamniotic twin pregnancy, following in vitro fertilisation for subfertility secondary to severe endometriosis. On admission, pain score was eight, with ten being the maximum of the scale. The vital signs were stable. Abdominal palpation revealed generalised tenderness with no guarding or palpable contraction. There was no evidence of bleeding and the cervical os was closed on speculum examination. The cardiotocograph (CTG) was pathological and a plan was made to deliver the babies with emergency caesarean section. Intraoperatively, there was massive haemoperitoneum which was managed successfully with the involvement of multidisciplinary input from general surgeons and urologists with optimum maternal and fetal outcome.

Objective. To find out the success rate of conservative management of complete two weeks for miscarriage in view of NICE Guideline 154.Design. Prospective observational study.Setting. Early pregnancy assessment units of District General Hospital in the United Kingdom.Participants. Women of less than 14 weeks’ gestation, with a diagnosis of miscarriage (missed miscarriage/anembryonic or incomplete miscarriage).Interventions.Expectant management for two weeks.Main Outcome Measure.(1) Efficacy of 2-week expectant management, that is, complete resolution of miscarriage based either on self-reporting of patient after passing products of conception at home between D0 and D14 of expectant management or confirmation on scan at D14, and (2) short-term complications needing strong analgesia, blood transfusion, and antibiotics.Results. Expectant management of miscarriage for 2 weeks from the day of diagnosis was successful in 58% (64 /111) and failed in 42% (47/111).Conclusions. Expectant management success rate is consistent with the results from the longitudinal studies and RCTs published in the past. It is a safe option as none of the patients on expectant/medical management needed strong analgesia/antibiotics or blood transfusion.

The aim of this study was to understand the TORCH test and to evaluate its significance in women with polyhydramnios in singleton pregnancies.Retrospective analysis of indications and results of TORCH referrals made from November 2007 to 2009 with detailed review of case notes of women with polyhydramnios who had TORCH test.The total number of deliveries during specimen time was 3004, out of which 110(3.6%) had serum TORCH screening. The main indication for this test was polyhydramnios 62 (56.36%) followed by obstetric cholestasis 20 (18.18%), Intra-uterine fetal demise 6 (5.45%), fetal anomalies 5(4.54%), and deranged liver function tests (LFTs) 2 (1.8%). 15 (13.6%) women had TORCH screening for other indications such as clinical polyhydramnios, increased nuchal translucency (2.5 mm). cytomegalovirus (CMV) and toxoplasmosis antibodies were tested in all cases whereas, parvovirus and herpes simplex virus screen were carried out in 4 (12.7%) and 2 (1.8%) patients, respectively. One woman (0.09%) had infection with CMV who had TORCH screening carried out for deranged LFTs. None of these women had positive TORCH screening giving the p value of0.0001. These women also did not have any associated perinatal or maternal mortality.While the sample size of this study is small to disregard the significance of TORCH test in polyhydramnios, the statistical evaluation shows that this test is not beneficial in women in whom polyhydramnios is an isolated ultrasound finding, especially when it is diagnosed in third trimester.

Infertility can arise as a consequence of treatment of oncological conditions. The parallel and continued improvement in both the management of oncology and fertility cases in recent times has brought to the fore-front the potential for fertility preservation in patients being treated for cancer. Oncologists must be aware of situations where their treatment will affect fertility in patients who are being treated for cancer and they must also be aware of the pathways available for procedures such as cryopreservation of gametes and/or embryos. Improved cancer care associated with increased cure rates and long term survival, coupled with advances in fertility treatment means that it is now imperative that fertility preservation is considered as part of the care offered to these patients. This can only be approached within a multidisciplinary setting. There are obvious challenges that still remain to be resolved, especially in the area of fertility preservation in prepubertal patients. These include ethical issues, such as valid consent and research in the area of tissue retrieval, cryopreservation, and transplantation.

In this case series, six women with high and very high body mass index (BMI; range, 30–65) underwent LAVH + bilateral salphingo-ophorectomy and removal of vaginal cuff under general anaesthesia for endometrial cancer. Initial Verres needle entry and insufflation was through the left upper quadrant at sub-coastal margin. With good surgical outcome, shorter hospitalisation and improved quality of life, we found that laparoscopic surgery was feasible in high and very high BMI patients with early stage endometrial cancer.

Laparoscopic surgery is frequently performed in gynaecology for a variety of indications. The most important step in laparoscopy is the creation of pneumoperitoneum and safe placement of the primary trocar. Initial entry with a Veress needle for CO2 insufflation was performed through the left upper quadrant, at the height of the dome of the lower margin of the sub-costal region. In the majority of cases, a single entry was successful in achieving CO2 insufflation. No visceral injury was noted with our technique in 442 laparoscopic procedures. This surgical landmark provides several advantages over other entry points and was feasible in 442 laparoscopies, irrespective of the patient characteristics, such as age, body mass index (BMI), previous surgical history and operative indications.

We present a case report of a successful pregnancy outcome in a woman diagnosed with Ehlers–Danlos syndrome (EDS) hypermobility type or type III. EDS is a group of connective tissue disorders that has a common genotypic defect, but heterogeneous phenotypic presentations. The variation in EDS manifestations can result in moderate to severe effects on life-expectancy for some types. A number of studies and a review of the literature indicate that generally in pregnant women with EDS, maternal and neonatal outcomes are favourable. However, in EDS type IV, pregnancy can be associated with serious maternal complications. Therefore, obstetrical management should be individualized. This paper discusses the obstetric management of a patient with EDS hypermobility type and compares it to other studies in the literature.

Retroperitoneal haematomas in obstetrics are uncommon. The causes and pathogenesis of retroperitoneal haematomas lack clarity and the aim of this review is to recognise retroperitoneal haematomas as a separate entity from commonly seen vaginal and pelvic haematomas. It is time to raise awareness among obstetricians to recognise retroperitoneal haematomas as an important cause of maternal morbidity and mortality which requires high clinical suspicion and multidisciplinary input. As retroperitoneal haematomas are rare but can cause serious threat to maternal wellbeing, resources should be directed towards their management. Existing guidelines of maternal collapse and morbidity during pregnancy and puerperium need to include retroperitoneal haematomas as one of the important causes of maternal shock or morbidity. New learning pathways should be opted for to increase awareness of retroperitoneal haematomas among obstetricians enabling them to reflect on their implications while managing retroperitoneal haematomas. Management of retroperitoneal haematomas is complex and continues to improve with advancements in the investigative strategies, treatment options and multidisciplinary involvement.

A 32-year-old Caucasian woman of body mass index (BMI) 46 presented with urinary symptoms to accident and emergency (A&E). Acute pyelonephritis was the diagnosis. Transabdominal scan revealed a live term fetus. Both the partners were unaware of the ongoing pregnancy until diagnosed. She underwent emergency cesarean under general anaesthesia (GA) for nonreassuring CTG, severe chorioamnionitis, and moderate preecclampsia. A live male baby weighing 4400 grams delivered in poor condition. Placental tissue on culture exhibited scanty growth of pseudomonas aeruginosa. Chorioamnionitis due to pseudomonas is rare, with high neonatal morbidity and mortality. It is mostly reported among preterm prelabor rupture of membranes (PPROM). Educating the community especially morbidly obese women if they put on excessive weight or with irregular periods should seek doctor's advice and exclude pregnancy. For the primary care provider, it is of great importance to exclude pregnancy in any reproductive woman presenting with abdominal complaints. This case also brings to clinicians notice that pseudomonas can be community-acquired and can affect term pregnancies with intact or prolonged rupture of membranes.

I congratulate Zeitlin and colleagues on publishing this paper,1 as the EPICE study means that we now have comprehensive data on individual countries from Europe in one place, and the evidence and information are like a DNA blueprint for neonatologists dealing with preterm births. Do the authors agree that the …

Key content Polyhydramnios is a common obstetric condition, but its management can often be challenging. Mild polyhydramnios resolves frequently and is not usually associated with adverse perinatal outcomes. There is a higher prevalence of aneuploidy (10–20%) in severe polyhydramnios. Unexplained polyhydramnios has been associated with increased rates of perinatal morbidity and mortality. Learning objectives To gain an overview of the aetiology and investigations for polyhydramnios in singleton pregnancies. To understand the implications of mild and unexplained polyhydramnios for both mother and fetus. To develop an evidence-based approach for managing this condition and provide a surveillance strategy. Ethical issues Can we justify the benefits of early induction in unexplained polyhydramnios in the face of associated risks?

Isolated torsion of fallopian tube is a rare event and often difficult to diagnose. This report describes such a condition in a patient who presented with pain lower abdomen and underwent laproscopy primarily by surgeons with the suspicion of appendicitis but eventually ended up in right salpingectomy because of isolated right tubal torsion. The issue of future fertility was obviously considered but unfortunately the tube could not be preserved because of necrosis and haemorrhage inside it. Tubal torsion should however be kept in mind in the differential diagnosis of lower abdominal pain in women of all ages.

Mid-gut volvulus is a rare complication of pregnancy, where torsion of the small bowel around its mesentery can result in extensive bowel infarction. To our knowledge, there has been no previous reported case of mid-gut volvulus and mesenteric vessel thrombosis managed without bowel resection. A 25-year-old woman presented at 35 + 3 weeks gestation with constant abdominal pain. There was no past medical history of abdominal surgery. The patient later developed feculent vomiting. Exploratory laparotomy revealed a mid-gut volvulus causing small bowel ischaemia, which extended from the duodenojejunal (DJ) flexure to the terminal ileum. There was also mesenteric arterial and venous thrombosis. A healthy baby girl was delivered by caesarean section and the mid-gut volvulus was reduced. Further, two re-look laparotomies confirmed viable bowel following detorsion. The mesenteric vessel thrombosis was treated with intravenous heparin. The patient went on to make a full recovery. As shown in this case, the volvulus and mesenteric vessel thrombosis may occur during pregnancy even in patients without previous history of coagulopathies and abdominal surgery. It is difficult to make a clinical diagnosis, as the symptoms, physical signs and laboratory findings can be misleading. Therefore, a high index of suspicion is necessary for the early diagnosis of these conditions, as prompt treatment can prevent bowel resection and improve maternal and foetal outcomes.

There is paucity of literature on retroperitoneal haemorrhage/haematomas (RH) as these cases are extremely rare in obstetrics. Experience is available mostly from case reports and therefore the incidence of RH in obstetrics is unknown.Literature search in Medline/Pubmed and Google scholar using MeSH; aneurysm, haematoma, haemorrhage, obstetrics and retroperitoneal.This article discusses aetiology, pathogenesis, diagnostic difficulties and dilemmas, as well as misleading symptoms that often mimic common clinical conditions.Management of RH is complex and continues to improve with advancements in the investigative strategies, treatment options and critical care specialty. Further the authors highlight the importance of basic principles of clinical examination, the need for multidisciplinary input and the current trend in the management options.

The process of assessing vulnerability in agriculture, water resources, marine and terrestrial ecosystems, and coastal zone management due to climate change requires construction of predicted vision of climate scenarios under physically reasonable assumptions of greenhouse gas levels. In arid and hot climatic conditions, even minor climatic changes will have significant impact on survival of plant species, wild animals, and other desert ecosystems as well as on human health. The paper presents future changes in temperature, precipitation and humidity in Yemen, Oman, UAE and Qatar under different scenarios using IPCC database derived through GCM's. Various climatic change scenarios developed by IPCC were reviewed, A2 and B2 climatic scenarios were selected for the study. Long-term simulated records derived by the following models were retrieved from the database: 1. Hadley Model -(HADCM3) 2. Canadian Climatic Model - (CGCM2) 3. National Center for Atmospheric Research Model - (NCAR-PCM) Using 1970-2000 values as baseline, variations in 2020-2050 and 2070-2099 were estimated and statistically analyzed to determine uncertainties in prediction. Summarized impacts of climate change on human health based on empirical approach for the region is presented in the paper to make it better prepared (adapted) to the climatic changes with recommendations on future capacity building in modeling and data collection.

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This paper describes the diagnostic difficulties in a patient who presented with massive puerperal spontaneous onset retroperitoneal Psoas muscle haematoma following normal vaginal delivery. Fortun...

A 26-year-old gravida 3 para 1+1 was referred for antenatal care. In her last pregnancy she had a early spontaneous preterm delivery at 32 weeks and 2 days complicated by intra hepatic cholestasis of pregnancy. She had a strong family history of ischemic heart and combined hyperlipidaemia. In view of her past obstetric history a baseline liver function test and fasting bile acid assay was carried out. Upto 21 week her Bile acids were normal but at 22 weeks her fasting bile acid assay increased to the upper limit of normal (9 micromol/L).Ursodeoxycholic acid was started from 28 weeks gestation on a dosage of 500 mg b.i.d., which was subsequently increased to 500 mg t.d.s. at 32 weeks.At 34 weeks she gave a history of occasional right upper quadrant abdominal pain and her biochemistry revealed raised serum aspartate transaminase ,alanine transaminase, fasting serum triglyceride and cholesterol levels 58 IU,79 IU/L,18.37 mmol/L and 25.7 mmol/L respectively. The triglyceride level was too high to calculate the low density lipoprotein cholesterol. A diagnosis of severe intrahepatic cholestasis of pregnancy in a patient with background familial combined hyperlipidaemia was made. Ultrasound abdomen and cardiotocography was normal. She had normal delivery. In cases of early onset cholestasis of pregnancy we suggest that lipid profiles are checked in these patients to rule out hyperlipidaemia and its attendant short term and long-term risks. More research will be required to ascertain if there is a link between these 2 disorders.

This case reports spontaneous pneumomediastinum in the second stage of labour leading to cardiovascular instability. Forceps were used to expedite delivery. Examination revealed characteristic crepitus of subcutaneous emphysema in the neck region, which was confirmed on chest X-Ray and CT scan. The patient was managed in the high dependency unit (HDU) for 48 hours and made a full recovery.