Search

We reviewed the studies about fertility-sparing in young patient presenting a benign ovarian tumor. It appears that more than the histologic nature of the ovarian cysts, it is the surgical treatment of the cyst which may decrease fertility. Some good practice of surgical procedures must be kept in mind when one manages a benign ovarian tumor in a young patient wishing to preserve her fertility: surgery should be avoided as much as possible; kystectomy is better than oophorectomy; no radical surgery should be done without pathological certitudes; electrocoagulation must be avoided on the cyst walls. In some situations, fertility is specially endangered: bilateral ovarian cysts, recurrence or strong probability of recurrence (endometriomas), poor ovarian reserve (previous chemo- or radiotherapy, age>35, premature ovarian failure). In these situations, a pre-operative assessment of the ovarian reserve could be useful. Beside the surgical 'good procedures', gamete cryopreservation procedures could be used. Cryopreservation of mature oocytes (after ovarian hyperstimulation) or in vitro mature oocytes (after antral follicle retrieval) can be proposed. Ovarian tissue cryopreservation is another option. Oocyte (or embryos) cryopreservation can be proposed before or after the surgery. The global management of benign ovarian tumors in young patients should be decided between surgeons and specialists in reproductive biology., (Copyright © 2013. Published by Elsevier Masson SAS.)

Objective: To determine whether a tumor necrosis factor-α (TNF-α) inhibitor can reduce the embryotoxicity of the peritoneal fluid (PF) of women with endometriosis., Design: Experimental clinical study., Setting: University hospital., Patient(s): Twelve women with chocolate cysts and 12 control women without endometriosis., Intervention(s): None., Main Outcome Measure(s): We collected the PF from patients with chocolate cysts (CH-PF) and patients without endometriosis (N-PF) during laparoscopic surgery. For the in vitro studies, development and apoptosis were evaluated in two-cell stage mouse embryos after incubation with CH-PF and N-PF, with or without a TNF-α inhibitor., Result(s): We found that CH-PF significantly decreased the rate of blastocyst development and increased the percentage of apoptotic cells in the embryos. Cytokine assays showed that the concentrations of several cytokines, including TNF-α, were higher in embryos incubated with CH-PF than in those incubated with N-PF. Furthermore, the treatment of embryos with TNF-α retarded development and induced apoptosis. Important, adalimumab, a TNF-α inhibitor, effectively abrogated the embryotoxicity that was induced by CH-PF., Conclusion(s): These data collectively highlight the crucial role of TNF-α in CH-PF-induced embryotoxicity and suggest that TNF-α inhibitors may be potential therapeutic agents for treating endometriosis-induced infertility., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: The study included patients suffering from stage III-IV endometriosis complicated by an endometrioma (OMA). We investigated the association between age, presence of dysmenorrhea/dyspareunia, preoperative CA 125 level, size of OMA on ultrasonographic exam and infertility as well as the risk of intraoperative detection of hydrosalpinx that was not suspected on pre-operative assessment., Materials and Methods: The study included patients with stage III-IV endometriosis complicated by OMA who underwent a laparoscopic or open surgery due to pre-diagnosis of infertility or adnexal mass., Results: Dysmenorrhea had statistically significant association with infertility (p=0.031). There was no statistically significant relation between age, dyspareunia, preoperative CA 125 level, size of OMA on ultrasonographic exam and infertility (p=0.203, p=0.561, p=0.561 and p=0.668, respectively). No statistically significant relation was found between age, CA 125 level, dysmenorrhea, dyspareunia and detection of an unilateral/bilateral hydrosalpinx, that was not suspected on pre-operative assessment (p=0.179, p=0.295, p=0.895, p=0.424, respectively). There was an association between OMA size (p=0.023) and detection of unilateral/bilateral hydrosalpinx., Conclusions: Patients who desire to have children but suffer from severe dysmenorrhea must be preoperatively informed about the possibility of having stage III-IV endometriosis. Infertile patients who are about to undergo an operation, especially due to a large OMA, may turn out to have hydrosalpinx. These patients should be informed preoperatively about the possibility of having salpingectomy or the proximal tubal surgery for improving fertility.

Background: Small follicular cysts are commonly found in the ovaries of prepubertal girls, and in most cases, they are of no clinical importance. These cysts are usually self-limiting and resolve spontaneously. However, occasionally, these cysts may enlarge and continue to produce estrogen, resulting in signs of sexual precocity. Here, we report a case of precocious pseudopuberty associated with an autonomous ovarian follicular cyst., Case Presentation: A 5.9-year-old girl initially presented to a local clinic with vaginal bleeding and a large unilateral ovarian cyst. At 6 months after the initial acute episode, the patient visited our hospital as the ovarian cyst had persisted and increased in size. Endocrinological examination showed elevated estrogen levels and suppressed gonadotropin levels on GnRH stimulation test. Also, no skin pigmentation or bone anomaly was noted. Based on these observations, laparoscopic cystectomy was performed, and histologic analysis confirmed the diagnosis of a follicular cyst. After the laparoscopic cystectomy, the patient's hormone levels returned to normal and no ovarian cyst was detected by ultrasound., Conclusions: As autonomous ovarian cysts are usually self-limiting disorder, no treatment is necessary. Therefore, surgical management should be deferred as long as possible to avoid the risk of repeat surgery, as pseudoprecocious puberty due to autonomous ovarian cysts can resolve spontaneoulsy and frequently recurs. Precocious pseudopuberty with an ovarian cyst may be due to granulosa cell tumor or may be one symptom of the McCune-Albright Syndrome (MAS). A careful longer-term follow up of patients with autonomous ovarian cysts and/or molecular studies may be necessary in such cases.

Single-port endo-laparoscopic surgery has gained support in the surgical community because it is perceived to offer a better postoperative outcome as it requires only a single incision. We write this prospective observational study to ascertain the feasibility and safety of this technique in patients otherwise requiring two operations. Five patients who underwent double procedures with a single-port device were reviewed: Case 1, a transabdominal preperitoneal hernia repair and gastric wedge resection; Case 2, cholecystectomy and diaphragmatic hernia repair; Case 3, oophorectomy and incisional hernia repair; Case 4, anterior resection of the rectum and hepatic segmentectomy; and Case 5, left adrenalectomy and cholecystectomy. Patient demographics, type of port used, operative time, complications and incision length were collected. Mean operative time for the cases ranged from 100 to 315 min. Incision length for the single-port device was 2 cm. In Case 2, an additional 5-mm port was used and an intraoperative complication involving a laceration of the liver occurred during the suturing of the gallbladder fundus. An additional 8-cm lower abdominal incision (Pfannenstiel) was required in Case 4 to complete the colonic anastomosis and for specimen retrieval. Single-port endo-laparoscopic surgery is a feasible and safe technique for approaching double procedures. It drastically reduces the number of scars that a double procedure creates, and if difficulty arises, another port can always be added to ease the operation. It can also potentially reduce the number of admissions and anesthesia that a patient undergoes., (© 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

Ovarian torsion may have significant fertility implications. Interleukin-6 is a pro-inflammatory cytokine, which may act as a helpful diagnostic test. Our objective was to investigate the accuracy of serum interleukin-6 in the diagnosis of ovarian torsion in women with ultrasonographic evidence of an ovarian cyst. An electronic search of published data, unpublished dissertations, theses and conference proceedings was performed. The systematic review involved observational studies. The studies had to provide data to construct 2 × 2 tables. A modified QUADAS tool was used to assess the quality of studies. Sensitivity, specificity, positive and negative predictive value, likelihood ratios and diagnostic odds ratios were calculated. Three studies were identified. Two were included in the meta-analysis. The prevalence of torsion was 30% (21/70). The pooled sensitivity was 85.1% and the pooled specificity was 84.1%. Although further cohort studies would be required, there may be a role for interleukin-6 in the diagnosis of ovarian torsion.

Objective: This study aimed to determine the outcome of children with unclear etiology for acute abdominal pain admitted to the emergency department observation unit (EDOU)., Methods: This is a retrospective cohort study of children 18 years or younger who presented with acute abdominal pain to a tertiary pediatric ED and were observed in the EDOU. Children with alternative explanations for abdominal pain were excluded. Patients were classified based on disposition, and data were analyzed using χ tests., Results: There were 237 patients included in the study (median age, 9 years; 46% male). Mean length of stay in EDOU was 14.4 hours. Fifty-four percent were evaluated by surgery. Two hundred (84%) were discharged; 37 (16%) were admitted, of whom 22 (9%) underwent surgical intervention (13 appendectomies, 6 ovarian cystectomies, 2 small-bowel obstructions, 1 cholecystectomy). Eight had acute appendicitis on pathology reports. The duration of symptoms, the presence of fever, nausea/vomiting, right-lower-quadrant pain, rebound tenderness, or leukocytosis greater than 10,000 cells/μL did not predict admission. Patients with diarrhea were more likely to be discharged home (P = 0.02). Intravenous hydration (86%) and pain control (63%) were the most common interventions in the EDOU. Abdominal pain not otherwise specified and acute gastroenteritis were the 2 most common discharge diagnoses. Eight (4%) of the 200 discharged patients returned to the ED within 48 hours, and all were discharged home from the ED., Conclusions: The majority of children admitted to the EDOU with abdominal pain have nonsurgical causes of abdominal pain. The EDOU provides a reasonable alternative for monitoring these patients pending disposition.

Objective: To assess the cause of pain on diagnostic laparoscopy in women with chronic pelvic pain and equivocal clinical and ultrasound examination., Study Design: Cross-sectional observational study., Place and Duration of Study: Red Crescent General Hospital, Hyderabad, Sindh, from January 2007 to December 2009., Methodology: All the women presenting with chronic pelvic pain for more than 6 months duration, without any obvious pathological findings on clinical as well as on ultrasound examination were recruited. Women with chronic pelvic pain and having pelvic pathological lesions detected on clinical and/or ultrasound examination were excluded. Clinical, ultrasound, and laparoscopic data was collected and analyzed on SPSS version 14. The results were described as frequency, proportion, compared by chi-square test with significance at p < 0.05., Results: Highest frequency of chronic pelvic pain was observed in women aged between 26 - 35 years (62.4%), 53 out of 85 women. Most of these women were married (90.6%) and nulliparous (47.1%). Pain was reported as dull and sharp by 35 women (41.2%), infertility (n = 46, 54.1%) and dyspareunia (n = 45, 52.9%) were the commonest co-existent complaints. On laparoscopic examination, pathological lesions were detected in 65, tuberculosis in 17 (20%) endometriosis in 11 women (12.9%), pelvic inflammatory diseases and pelvic adhesion in 8 (9.4%) women each and ovarian cyst in 6 women (7.1%)., Conclusion: Positive laparoscopic yield was high in women with pelvic pain. Pelvic tuberculosis was the most common pathology detected followed by endometriosis, pelvic inflammatory disease and adhesions.

Reports of hyperreactio luteinalis in a spontaneously conceived pregnancy are uncommon. Hyperreactio luteinalis complicated by polyhydramnios without an identifiable cause has never been reported. The authors report a case of a 25-year-old, gravida 4, para 2-0-1-2, 16-week pregnant woman who presented with bilateral ovarian enlargement. The beta-human chorionic gonadotropin hormone was at a normal level. An exploratory laparotomy with biopsy was performed at 17 weeks of gestation. Polyhydramnios without an identifiable cause was detected at 30 weeks of gestation. A full-term healthy baby was delivered. Intrapartum and postpartum were unremarkable and both ovaries spontaneously regressed.

This 32-year old patient presented at seven weeks gestation with severe left-sided lower abdominal pain. This was against the background of a previous history of left salpingectomy from a ruptured ectopic gestation seven years previously. Transvaginal sonographic evaluation revealed a viable seven week intrauterine embryo, a 2 cm left corpus luteum cyst and Doppler studies revealed reduced internal flow. This led the way for a conservative approach via laparoscopy of untwisting the pedicle to restore blood flow In this case, the ovarian ligament was shorted using 1/0 vicryl and the pregnancy went to term.

Simultaneous bilateral adnexal torsion is very rare especially in adults. There have been few cases reported in children with only one previous case reported in adults since 1984, which was complicated by entanglement of both adnexae. In adults, the use of ovarian stimulation for treatment of infertility can increase the risk of ovarian torsion. We report the second case of simultaneous bilateral adnexal torsion in an adult female without follicular stimulation.

Objective: The aim of our study was to evaluate the practice of Lille in the management of ovarian cyst during pregnancy and to compare our results with data from the literature., Patients and Methods: The study was a retrospective cohort of Lille University Hospital between 1st January 2007 and 31st December 2010. The inclusion was based on the ultrasound diagnosis of an ovarian cyst greater or equal to 30mm during pregnancy. Obstetrical and neonatal data, surgical techniques and indications were analyzed., Results: Seventy-one patients had a diagnosis of ovarian cyst during pregnancy, i.e., 0.35% of pregnancies followed at the University Hospital of Lille during the study period. The diagnosis took place in the first quarter in the majority of cases, at 12.30±6.99 weeks of amenorrhea (WA). Most often, the ovarian cyst is monitored during pregnancy, which has been strictly the case in 63.38% of cysts (45 patients). Fourteen patients had to be operated during pregnancy (19.72%). There were 7 emergency interventions and 7 programmed intrapartum interventions. Five intrapartum laparoscopies were performed at a mean term of 14.75±2.63 WA, and 9 laparotomies were performed at a mean term of 18.88±4.57 WA. Twelve ovarian mass surgeries were performed per caesarean section. Operated cysts are most often organic cysts (74.39%). No malignancies were observed, and 3 cases of borderline tumors were diagnosed. There were no obstetrical or neonatal complications., Discussion and Conclusion: A simple monitoring is possible if the cyst is benign, less than 6cm and does not change. Surgery is required in an emergency or in case of suspicious signs of complications or malignancy. Laparoscopy can be widely used until the 2nd quarter. Lille's attitude respects the recommendations is consistent with the literature., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

This is the first reported case of a sebaceous adenoma arising within an ovarian mature cystic teratoma in a patient with Muir-Torre syndrome. The pathologic findings and a literature review are presented, including the importance and possible benefits of an early diagnosis of Muir-Torre syndrome. It is proposed that the presence of a sebaceous adenoma in an ovarian cystic teratoma may serve as a useful trigger to consider further history and investigations, with the goal of identifying an important genetic cancer predisposition syndrome., (Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aims to present the clinical characteristics of a series of postmenopausal women with endometriosis and to evaluate the preferential location, extension and histopathological features of the lesions., Methods: We retrospectively examined the clinical records of 72 postmenopausal women with endometriosis who underwent surgery between January 1998 and December 2010., Results: The median age of patients at the time of surgery was 58.5 years. Eleven patients (15.3%) had previous history of endometriosis and five patients had previously undergone surgery for this reason. Only two patients included in the study were using hormone replacement therapy at the time of surgery. The most frequent location of endometriotic lesions was the ovary and among patients with endometriomas, 35% (20/57) had different grades of metaplasia, hyperplasia, atypia and endometrioid carcinoma arising in endometriosis. The proportions of epithelium, stroma and hemorrhage in endometriotic lesions were higher in patients with concomitant endometrial or ovarian cancer., Conclusions: Endometriosis should be considered in the differential diagnosis of postmenopausal cystic lesions of the ovary. The administration of exogenous estrogen is not a prerequisite for the presence of endometriosis in postmenopausal women, and histological signs of functionally active lesions were also observed in the absence of exogenous hormone intake.

Ovarian torsion is an uncommon condition which may affect women of any age. In a significant number of women, it may be associated with a concomitant pathology such as a cyst. Presently, there is no single diagnostic tool with significant predictive value. Multimodal diagnostic tools hold promise of early accurate diagnosis; prospective studies are required to assess the validity of such tools. This would enable wider application of ovarian function preserving procedures. Further, an assessment of the psychological impact of oophorectomy should be studied in order to facilitate the optimal tailored care.

Context: Endometriomas are mainly treated surgically. However, there has been concern over the potential damaging effect of this surgery on ovarian reserve., Objective: The aim of this meta-analysis was to investigate the impact of surgery for endometriomas on ovarian reserve as determined by serum anti-müllerian hormone (AMH)., Data Sources: MEDLINE, PubMed, and Embase were searched electronically., Study Selection: All prospective cohort studies that analyzed changes of serum AMH concentrations after surgical treatment of endometriomas were eligible. Twenty-one studies were identified, of which eight were selected for meta-analysis., Data Extraction: Two reviewers performed the data extraction independently., Data Synthesis: Pooled analysis of 237 patients showed a statistically significant decrease in serum AMH concentration after ovarian cystectomy (weighted mean difference -1.13 ng/ml; 95% confidence interval -0.37 to -1.88), although heterogeneity was high. Sensitivity analysis for studies with a preoperative serum AMH level of 3.1 ng/ml or greater improved heterogeneity but also still showed a significant postoperative fall in serum AMH (weighted mean difference -1.52 ng/ml, 95% confidence interval -1.04 to -2)., Conclusion: The results of this study suggest a negative impact of excision of endometriomas on ovarian reserve as evidenced by a significant postoperative fall in circulating AMH.

There are few reports of multiple ovarian cysts secondary to hypothyroidism, and multiple ovarian cysts associated with pregnancy most commonly occur in association with assisted reproductive technologies. Herein, we report a case of a naturally conceived pregnancy occurring 2 years after stopping treatment for primary hypothyroidism. The patient developed multiple ovarian cysts in the first trimester, and laboratory studies and ultrasonography were consistent with hypothyroidism. Herein, we present the case and discuss the importance of prenatal screening for hypothyroidism.

Congenital adrenal hyperplasia (CAH) is a group of disorders affecting the adrenal steroid synthesis. The most common form, 21-hydroxylase deficiency (21-OHD), leads to decreased production of cortisol and aldosterone with increased androgen secretion. In classic CAH, glucocorticoid treatment can be life-saving and serves to bring the symptoms under control. However, the treatment challenge is to effectively control the excess androgen effect by using the lowest possible glucocorticoid dose. Previous studies suggested a relationship between ovarian cyst formation and adrenal androgen excess, but neonatal large ovarian cysts have been very rarely reported in newborns with CAH. Here, we present the unique case of a neonate with classical 21-OHD who underwent surgery for a giant (10x8x7 cm) unilateral solitary ovarian follicular cyst on the 2nd postnatal day. Hormonal evaluation of the patient revealed high-dose hook effect for serum testosterone levels for the first time by a two-site immunoradiometric assay. Possible mechanisms by which androgen excess may cause ovarian cyst formation are discussed.

Introduction: This study sought to evaluate the outcomes of in-hospital delay and determine associated co-morbidities in the treatment of pediatric acute appendicitis., Methods: This was a retrospective analysis of the national inpatient sample from 2000 to 2008. Immediate treatment was defined as treatment in hospital day 0 or 1. Delay in treatment was defined as treatment in hospital day 2 and beyond., Results: During the study period, 683,016 pediatric appendicitis were identified. 17,737 (2.6%) experienced a delay in treatment. Multivariate analysis identified associated co-morbidities for delay in treatment: ALL (OR 12.84, CI 11.04-14.94), AML (OR 9.41, CI 7.58-11.68), neutropenia (OR 5.53, CI 4.60-6.65), and ovarian cyst without torsion (OR 3.17, CI 2.94-3.42). Surgical management included more than 13-fold increase in drainage procedures (5.5 vs. 0.4%), sixfold increase in cecectomy (1.2 vs. 0.2%), 14-fold increase in hemicolectomy (1.4 vs. 0.1%), 11-fold increase in small bowel laceration suture repair (1.1 vs. 0.1%), and 15-fold increase in small bowel resection (1.5 vs. 0.1%)., Conclusions: In-hospital delay beyond 2 days is associated with significant negative outcomes with regard to complications, economic burden, and subsequent surgical management. Using the co-morbidity index, high-risk co-morbidities with associated delay in treatment were identified.

Operating room fires occur very rarely. Nevertheless, a disaster can complicate almost any kind of surgery. The majority of operating room fires result from the use of alcohol- based surgical preparation solutions, electro-surgical equipment, or flammable drapes in an oxygen-rich environment. We report a patient with an ovarian cyst and uterine myomas who suffered a flame burn while undergoing gynecological surgery.

It has been reported that urticaria may be associated with some conditions characterized by sex hormone changes. The case presented concerns a 19-year-old patient who had severe symptoms of chronic urticaria for 3 years, concomitant with an irregular menstrual cycle and functional ovarian cysts. After a laparoscopic ovarian cystectomy the patient was treated with hormonal contraceptives. After 3 weeks the symptoms of urticaria withdrew. The patient continues to receive oral contraceptive treatment, has regular menstruation and shows no symptoms of urticaria. A diagnosis with an urticaria origin should take into consideration any changes in hormone balance as one of the possible reasons for the disease. In such cases, treatment with sex hormones may positively influence the course of the illness.

Contemporary management of ovarian cysts in the adolescent consists of conservative management, whether expectant, medical, or surgical. An understanding of ovarian physiology in the perimenarcheal and postpubertal patient supports ovarian preservation surgery, as the rate of malignancy is low and the alternative can be devastating. The most common ovarian cysts in adolescents are functional and often regress without further treatment. Symptomatic ovarian cysts warrant further investigation. Endometriomas arising from endometriosis are extremely uncommon. Tubo-ovarian abscesses are managed medically and rarely by drainage or surgery. Ovarian torsion is a surgical emergency, and prompt conservative operative management is indicated. Consideration of additional imaging, tumor markers, and surgical management of persistent or complex masses with ultrasound findings suspicious for malignancy is appropriate. This article reviews all these conditions and conservative management using laparoscopy as the preferred method if surgical intervention is needed. Unilateral removal of malignancies is advocated when possible.

We report the case of a 35-year-old nulliparous woman, with a previous history of ovarian cystectomy diagnosed 3 years earlier due a struma ovarii type of monodermal teratoma in the right ovary and a hemorrhagic cyst in the left ovary. Progressive growth of the left adnexal mass was observed in the periodic medical check-ups. Due to this, a second laparoscopy was performed and, based on the findings, a left ovarian cystectomy, right salpingectomy and resection of multiple peritoneal implants were carried out. The pathology diagnosis was left struma ovarii and peritoneal strumosis. A whole body and SPECT/CT scan with (99m)Tc-pertechnetate was performed to detect possible peritoneal implants. This study helped to make the therapeutic decision., (Copyright © 2011 Elsevier España, S.L. y SEMNIM. All rights reserved.)

The association in young females of long-standing primary hypothyroidism, isosexual precocious pseudopuberty and multicystic enlarged ovaries was first described in 1960 by Van Wyk and Grumbach. Since then, sporadic case reports have contributed to clarifying the key features of this syndrome. The unique elements that lead to this diagnosis are FSH-dominated sexual precocity combined with a delayed bone age in the presence of hypothyroidism. It is important to recognise this syndrome because initiating simple thyroid hormone replacement completely resolves symptoms and hormone abnormalities, avoiding unnecessary investigations for malignancies or surgical intervention. We describe an 8-year-old girl with autoimmune thyroiditis and severe long-standing hypothyroidism presenting with the clinical features of Van Wyk-Grumbach syndrome, a secondary TSH-secreting adenoma and hyperprolactinaemia. In addition, this girl presented with microcytic anaemia, elevated erythrocyte sedimentation rate (ESR) and two unusual features - a newly developed streaky hyperpigmented skin lesion and parathyroid hormone suppression despite vitamin D deficiency. Thyroxine replacement normalised all hormone abnormalities and shrunk the pituitary adenoma within 9 months, but the new skin lesion persisted. We review the literature and explore the pathophysiology of known and new features that give rise to speculation indicating stimulation of the FSH G protein-coupled receptor by excessive TSH, but LH suppression by hyperprolactinaemia.

We report the case of a premenarchal eight-year-old girl with an adnexal torsion accompanied by acute pyelonephritis with vague, non-specific symptoms. In young girls, symptoms may be vague, with patients complaining of non-specific gastro-intestinal problems. Combination with other complications such as pyelonephritis makes the diagnosis of adnexal torsion even more difficult as in the present case. To preserve future reproductive function, early surgical intervention is required. Although the impact on menarchal development of oophorectomy or partial removal of ovarian tissue before menarche remains to be evaluated, timely recognition and treatment of adnexal torsion clearly increases the possibility of retaining the ovary. Therefore, to decrease the time between the onset of symptoms and the identification of patients at risk, sonography should be considered as a first imaging modality for evaluating children with any degree of abdominal pain accompanied by non-specific symptoms., (© 2010 The Authors. Journal of Paediatrics and Child Health © 2010 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Objectives: Abdominal palpation with Ou MC manipulation (APOM) has showed to be more sensitive than bimanual pelvic examination for the diagnosis of pelvic inflammatory disease in women with acute abdomen (JEM. 2010;). This study compared APOM with traditional abdominal palpation (AP) for diagnostic reliability and enquired into the mechanism of APOM., Methods: From January 2006 through December 2009, 113 women with acute abdomen attending an emergency department received AP and APOM. Of the 113 women, 91 had pelvic organ disease, whereas 21 had nonpelvic organ disease and 1 had pelvic and nonpelvic organ disease concurrently., Results: Excluding the case with concurrent pelvic and nonpelvic organ disease, the sensitivity of APOM for the diagnosis of pelvic organ disease was significantly greater than that of AP (P=.003). Abdominal palpation with Ou MC manipulation also showed greater specificity of excluding pelvic organ disease than did AP (P=.003). Overall, 37.2% of patients with muscle guarding had repeated APOM or APOMs with aggravated isolation, which made the location of the diseased organ more distinct to identify., Conclusions: The delimitation by APOM as a separation zone may allow positional recognition of the tenderness with decreased overlap of signs. However, in cases with muscle guarding, initial APOM might not be able to locate tenderness effectively until repeated APOM or APOMs with aggravated isolation lead to extensive space shielding and isolation of visceral organs. This implies that tenderness location by APOM may also relate to space shielding and pelvic organ isolation., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The congenital central hypoventilation syndrome (CCHS) or Ondine's curse is a rare autosomal dominant disease, characterized by disorders of the autonomic nervous system, with abnormal ventilatory responses to hypercapnia and hypoxia. PHOX2B has been identified as the major gene causing CCHS. It results from polyalanine repeat expansion mutations. It typically presents in the newborn period but some cases have been described in adults (late onset CCHS) reflecting the variable penetrance of PHOX2B mutations., Case Report: A 48 year-old woman presented, after ovarian cyst surgery, with severe hypoventilation requiring intubation. Arterial blood gases revealed a PaO2 of 6.6kPa (50mmHg), a PaCO2 of 10kPa (80mmHg) and a pH of 7.22. The past medical history revealed nocturnal symptoms for a few years. These included apnoeas, fitful sleep and awakening with headaches. Physical examination, pulmonary function tests, lung tomography and magnetic resonance imaging of the brainstem were all normal. Polysomnography revealed numerous central and obstructive apnoeas and hypopnoeas, with severe hypoxaemia and hypercapnia. Hypoxic and hypercapnic stimulation tests showed no adaptation of the ventilatory responses. Genetic analysis showed a heterozygous five alanine expansion mutation of the 20-residue polyalanine tract in exon 3 of the PHOX2B gene., Conclusion: The diagnosis of late onset CCHS should be considered in patients with unexplained hypoventilation, and physiological evaluation should be undertaken to document the abnormal ventilatory responses. The presence of a PHOX2B mutation confirms the diagnosis., (Copyright © 2012 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Ovarian torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of ovarian torsion that was managed by transvaginal ovarian cystectomy in a 27 week gravid patient., (Copyright © 2012 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: A 36-year-old woman presented to her primary care physician with right lower abdominal pain. Her physician subsequently requested a CT to rule out appendicitis. Contrast-enhanced CT was performed and revealed no evidence of appendicitis but showed two subcutaneous ovoid soft-tissue masses anterior to the rectus sheath in the upper pelvis. Pelvic MRI confirmed the two masses, which showed mild enhancement. The objective of this article is to discuss a diagnostic approach to subcutaneous soft-tissue masses in the abdominal wall. Diagnosis was endometriosis of the abdominal wall., Conclusion: Integrating salient imaging findings with clinical history is crucial when approaching the diagnosis of subcutaneous soft-tissue masses. The diagnosis of endometriosis should be entertained when soft-tissue masses are seen in the distribution of a cesarean section scar in a woman of reproductive age. Pain, particularly with a cyclic pattern, is highly suggestive of endometriosis. If endometriosis is suspected on CT or ultrasound, MRI can be performed for further evaluation. Definitive diagnosis is made with biopsy. Because subcutaneous nodules are so amenable percutaneous biopsy, imaging features, although of interest, are somewhat ancillary to the diagnostic workup.

Background: Abdominal pain is one of the most common complaints made by patients visiting emergency departments; however, ovarian torsion is an uncommon cause of abdominal pain, especially in young children. Early diagnosis is essential in order to salvage the ovaries. We performed a retrospective analysis of patients under 18 years of age who visited Changhua Christian Hospital with adnexal torsion between June 2003 and June 2010., Methods: Medical records were reviewed for age, associated symptoms, past and present medical histories, physical findings, diagnostic tests performed, clinical course, pathological findings, and diagnoses., Results: A total of 21 patients were identified and included in the analysis; their mean (SD) age was 13.62 (3.75) years. Abdominal pain was the universal symptom. Vomiting or nausea was the second most common symptom (33.3%). The average period between symptom onset and diagnosis was 3.29 (6.39) days. Right-side adnexal torsion occurred in 14 patients, and left-side torsion in seven patients. Ovarian cysts, most often dermoid cysts (e.g., teratomas), were found in 16 patients (76%). Except for one conservatively treated case and one malignant case (adult granulose cell tumor), the other results of the pathological examination were as follows: eight dermoid cysts, two cystadenomas, one follicular cyst, and eight simple cysts., Conclusion: Although it is uncommon, adnexal torsion should be included in the differential diagnosis of lower abdominal pain in all girls, regardless of age. Sonography is helpful for making such a diagnosis. Time is a critical factor, and early laparoscopy or laparotomy may save a viable ovary., (Copyright © 2012. Published by Elsevier B.V.)

Purpose: To evaluate the blood flow changes and their relationships to microvessel density (MVD) and thrombospondin-1 (TSP-1) by transvaginal colour Doppler sonography (TV-CDS) in the ovarian interstitium to predict ovarian interstitial microvascular injury in the pathological process of ovarian endometrial cysts (OEC)., Methods: TV-CDS was preoperatively performed to detect blood flow changes in 60 patients with 76 ovarian endometrioid cysts, and flow classification and resistance indices (RI) values were recorded for analysis. Ovarian interstitial specimens with blood flow signals were collected for postoperative pathologic examination. TSP-1 protein was evaluated by immunohistochemistry and Western blot, TSP-1 mRNA by reverse transcriptase polymerase chain reaction, microvessels by CD34 antibody, and MVD by image analysis. Thirty age-matched patients with benign ovarian tumours served as controls., Results: Blood flow, most of star-shaped, within ovarian interstitial arteries in the OEC group was diminished; however, arterial spectra exhibited a high-resistance flow manifesting a significantly higher RI compared with that of the control group (P < 0.01). In ovarian interstitial specimens, there were significantly (P < 0.01) lower CD34-MVD and higher TSP-1 protein and mRNA in the OEC group than in the controls. CD34-MVD and TSP-1 showed remarkably negative correlation (rs = -0.76, P < 0.01). RI values correlated negatively with MVD values (rs = -0.91, P < 0.01), but positively with TSP-1 (rs = 0.81, P < 0.01), while flow classification correlated positively with MVD values (rs = 0.66, P < 0.01), but negatively with TSP-1 (rs = -0.54, P < 0.01)., Conclusions: Changes in CD34-MVD and TSP-1 reflected ovarian interstitial microvascular injury of OEC, pathologically supported the findings of blood flow changes within ovarian interstitial arteries, and prospectively predicted OEC-induced ovarian interstitial vessel injury. This has important clinical value: early treatment, instead of allowing the cyst to become bigger, is of great importance for OEC patients, because a greater number of functional tissue blood vessels would be destroyed as the disease progresses.

Objective: To present a case of a young woman with ovarian endometrioid adenocarcinoma arising from an endometriotic cyst and review of the literature., Case Report: A 33-year-old woman, gravid 2, para 2 was admitted to our department with a 5 cm adnexal mass. Diagnostic laparoscopy was performed and pathological examination demonstrated an endometriotic cyst with an area of an ovarian endometrioid adenocarcinoma well differentiated, with no capsular invasion. One month after the operation the patient underwent MRI which revealed a 6 cm mass in the Douglas pouch. The multidisciplinary oncology council decided on exploratory laparotomy, which revealed no pathology. After that the multidisciplinary oncology council decided on adjuvant chemotherapy and the patient received four cycles of carboplatin/taxol., Conclusion: It should always be considered that even when there are no risk factors for malignancy occurrence, a high index of suspicion is necessary and will help to prevent delay in the diagnosis of this rare neoplasm.

Glanzmann's thrombasthenia (GT) is a very rare autosomal recessive genetic bleeding disorder. Women with coagulation abnormalities are at increased risk of corpus luteum rupture and haemoperitoneum. Here we present a severe case of GT resulting in a haematoma extending from the pelvis to the liver that could only be controlled by surgery and intra-abdominal tranexamic acid., (Copyright © 2012 S. Karger AG, Basel.)

Bioactive gonadotropin-secreting pituitary adenomas are very rare in fertile women and can cause an ovarian hyperstimulation syndrome (OHSS). A 31-year-old woman with oligo-amenorrhea, severe ovarian cystic swelling and high serum estradiol was submitted to the resection of ovarian cysts and then treated with long-acting leuprolide 11.25 mg. Two months later, the ovarian multicystic hyperplasia relapsed, thus a pituitary MRI was performed and a pituitary macroadenoma was detected. In January 2010, she was referred to our Endocrinology Department where her hormonal evaluation showed high serum estradiol, FSH, α-subunit and inhibin with low LH. In April 2010, she underwent a trans-sphenoidal pituitary adenomectomy, which rapidly regularized the hormonal profile, the ovary and pituitary morphology and the menses. The case presented confirms that gonadotrophinomas occurring in reproductive-aged women frequently produce symptoms of ovarian hyperstimulation and proves that the use of GnRH analogs is not indicated in this condition.

Unlabelled: BACKGROUNDŕ: Hyperreactio luteinalis is a rare condition that stems from theca cell hyperplasia in the ovaries due to a high level of human chorionic gonadotropin during gestation. It occurs commonly in pregnant patients with trophoblastic disease, occasionally in multiple pregnancies, and rarely in normal singleton pregnancy., Case Report: A 24-year-old pregnant woman, G3 P0, who was admitted to the Perinatology Clinic with increasing findings of virilization during pregnancy was presented. The patient had bilaterally enlarged multicystic ovaries on sonographic examination and elevated serum androgen levels She was managed conservatively until 38th week of gestation as a presumptive diagnosis of hyperreactio luteinalis. Elevated blood pressure and prominent proteinuria were detected during the follow-up of the patient and labor was induced. She underwent an emergency caesarean delivery because of fetal distress. During caesarean section, ovarian biopsies were taken and a histopathological diagnosis of hyperreactio luteinalis was determined. The female fetus also presented virilization., Conclusion: Although infrequent, hyperreactio luteinalis with both maternal and fetal virilization can occur in women with spontaneous singleton pregnancies. The clinical manifestations in such women may be complicated by severe preeclampsia.

Ectopic thyroid tissue in ovarian teratoma or in struma ovarii appears to be histologically identical to the thyroid gland tissue and may virtually exhibit all the pathological patterns found in the thyroid gland. However, the concurrent lymphocytic infiltration of the thyroid gland, as found in Hashimoto's thyroiditis, and of the ectopic thyroid tissue is extremely rare. We describe the case of an 18-years old patient, in which a right ovarian 4 cm cyst has been found during pelvic ultrasound exam. The cyst was resected and microscopic examination of the mass revealed a mature cystic teratoma in which epidermal-like lining with skin adnexa, admixed with respiratory type epithelium, and areas of mature fatty, chondroid and dentigerous tissues were found. In a peripheral area of 0.7 cm  ×  0.5 cm, a prominent lymphocytic infiltrate surrounding thyroid follicles was identifiable. Thyroid function evaluation at different time points after surgery, revealed the development of mild hypothyroidism. Anti-TPO and anti-Tg autoantibodies were elevated, at fine needle aspiration biopsy a lymphocytic infiltrate, compatible with Hashimoto's thyroiditis, was present. We report here a rare case of Hashimoto's thyroiditis occurring both in the thyroid and in the ectopic thyroid tissue in the context of a benign cystic teratoma of the ovary.

The association between primary hypothyroidism and precocious puberty secondary to ovarian hyperstimulation has been recognized for over a century. Here, we report the case of a 9-year-old girl with severe primary hypothyroidism, who presented with premature menarche, enlarged pituitary gland, enlarged ovaries with multiple cysts, and elevated prolactin and alpha-feto protein levels. Pituitary and ovarian radiology findings, and alpha-feto protein levels normalized a few weeks after hypothyroidism treatment was started. Reviewing the literature we found several reports of increased levels of tumor markers in girls with this association. Thyroid function tests should be always part of the evaluation of patients with precocious puberty especially if the bone age is delayed. Tumor markers and liver function tests may be abnormal in patients with severe hypothyroidism and improve soon after thyroid hormone replacement is started.

Borderline para-ovarian cysts (PCs) are rare entities. They are commonly present in the third decade. Borderline PCs are often discovered fortuitously on routine ultrasound examination or they are common incidental findings during a laparotomy. They must be differentiated from simple ovarian cysts, peritoneal inclusion cysts and hydrosalpinges on ultrasound sonography. Papillary projections on the cyst wall should be searched carefully to suggest diagnosis. The treatment is surgical including fertility -sparing operation or more radical surgery depending on the case. The prognosis is good because borderline PCs are usually early-stage at diagnosis. Here is a report of a 38- year old woman with a borderline paratubal cyst. Adnexal torsion of hydrosalpinx was suspected; thus, she underwent an urgent surgery. Cystectomy was performed without rupture. The final diagnosis revealed a borderline PC. The patient underwent a radical surgery. Currently, she has had no evidence of disease recurrence.

Objective: To assess risk factors, clinical findings and mode of diagnosis and treatment in premenarchal children with surgically verified ovarian torsion (OT)., Study Design: A retrospective case review (Canadian Task Force Classification II-2)., Setting: Teaching and research hospital, a tertiary center., Patients: Premenarchal children with surgically verified OT., Interventions: Patients underwent either laparoscopy or laparotomy., Results: Twenty-two cases of OT in 20 premenarchal girls (median age 12 years) were identified. Three cases involved recurrent torsion after detorsion without cystectomy. The main presenting symptoms were sudden pain and vomiting. Six patients underwent Doppler examinations, and all demonstrated an abnormal flow. Seventeen interventions were by laparoscopy. Conservative management, mainly detorsion with additional cyst drainage or cystectomy, was performed in 19 cases (86.4%). Oophoropexy was performed in 3 cases (13.6%). Pathologic examination demonstrated 5 simple cysts and 1 dermoid cyst., Conclusions: Ovarian torsion in premenarchal girls usually presents with intermittent abdominal pain and abdominal tenderness. Other signs and symptoms are nonspecific. When performed, Doppler imaging may assist in diagnosing ovarian torsion in children. Detorsion followed by cystectomy may prevent recurrence., (Copyright © 2012 AAGL. Published by Elsevier Inc. All rights reserved.)

Von Willebrand disease (VWD) is the most common inherited bleeding condition that involves extended or excessive bleeding, caused by the deficiency or defect of von Willebrand factor (VWF). Hematoperitoneum as a complication of gynecologic diseases represents acute condition which is usually caused by the hemorrhagic corpus luteum or a rupture of either ectopic pregnancy or a hemorrhagic ovarian cyst. The authors present a unique case of conservatively managed massive hematoperitoneum caused by ovulation in a patient with severe form of von Willebrand disease who had right adnexectomy due to hemorrhagic corpus luteum four months prior. This conservative management by blood product and factor concentrate support could be a method of choice in selected hemodynamically stable patients. Furthermore, recurrent bleeding episodes following ovulation could be prevented by suppression of ovulation using oral contraceptive pills.

Objective: To use postoperative examination by three-dimensional (3D) ultrasound to compare loss of ovarian parenchyma after ovarian endometrioma ablation with the use of plasma energy versus cystectomy., Design: Retrospective "before and after" comparative study., Setting: University tertiary referral center., Patient(s): Thirty women with no previous history of ovarian surgery managed for unilateral ovarian endometrioma >30 mm in diameter., Intervention(s): Endometrioma ablation using plasma energy and ovarian tissue-sparing cystectomy., Main Outcome Measure(s): 3D ultrasound assessment of postoperative reduction in ovarian volume and antral follicle count (AFC)., Result(s): Fifteen women with comparable baseline characteristics were managed by each technique. Those who underwent cystectomy showed a statistically significant reduction in ovarian volume and AFC when compared with women who underwent ablation using plasma energy. Multivariate analysis showed that the relationship between the decrease in ovarian volume and AFC and the use of cystectomy remained statistically significant after adjustment for age, previous pregnancy, and cyst diameter., Conclusion(s): When compared with plasma energy ablation, cystectomy is responsible for a statistically significant decrease in ovarian volume and a statistically significant reduction in AFC. This data should be taken into account in therapeutic decision-making concerning women attempting pregnancy, especially where there are other risk factors for postoperative ovarian failure., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)