Significance of specialised preconception counselling in oocyte donation pregnancy with prior history of postpartum eclampsia

alkiviadis.1961 shared this article with you from Inoreader Significance of specialised preconception counselling in oocyte donation pregnancy with prior history of postpartum eclampsia Via BMJ Case Reports Last 6 Issues A well-known complication in oocyte donation (OD) pregnancy is preeclampsia. Here, we present a 31-year-old woman, pregnant after OD. She conceived by the reception of the oocyte from her partner (ROPA) and sperm from a sperm donor. She developed preeclampsia with severe features, necessitating caesarean delivery at 29 weeks' gestation due to deterioration of her clinical condition. Admission at the intensive care unit postpartum was necessary, because of recurrent postpa rtum eclampsia and administration of high dose magnesium sulphate for convulsion prophylaxis. This case illustrates the importance of preconception counselling for patients who are considering to conceive by OD and double gamete donation. In this specific case an alternative way to conceive was available. However, ROPA was preferred as part of shared lesbian motherhood. The risk of complications in the subsequent pregnancy has led to an alternative decision to accomplish a second pregnancy. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Haemorrhagic nasal polyp mimicking melanoma in an 83-year-old on rivaroxaban

alkiviadis.1961 shared this article with you from Inoreader Haemorrhagic nasal polyp mimicking melanoma in an 83-year-old on rivaroxaban Via BMJ Case Reports Last 6 Issues An 83-year-old woman presented with rapid onset unilateral nasal obstruction after sneezing. She had a history of hypertension and atrial fibrillation, and was on rivaroxaban. Examination revealed a dark red polypoidal lesion completely obstructing the left nostril. She underwent CT and MRI, and proceeded to urgent excision biopsy of the lesion. Intraoperative appearance was in keeping with a haemorrhagic polyp arising from the nasal septum. Histology revealed haematoma wi thin a layer of nasal mucosa. There was no evidence of haemangioma underlying the polyp. Our literature search has identified this case as the first described haemorrhagic polyp of the nasal septum. It is likely that rivaroxaban contributed to the formation of this haemorrhagic polyp, and it is important to differentiate benign haemorrhagic lesions from malignant conditions such as melanoma. Similar cases may become more common in the future as the proportion of the population on anticoagulants increases. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Management of pregnancy in case of multiple and giant uterine fibroids

alkiviadis.1961 shared this article with you from Inoreader Management of pregnancy in case of multiple and giant uterine fibroids Via BMJ Case Reports Last 6 Issues Uterine fibroids are common among women of reproductive age. During the pregnancy, the potential complications of fibroids, although rare, are of frequent clinical concern. Available studies describing management and obstetrical outcomes in pregnant women with giant fibroids are limited. We present the case of a 39-year-old pregnant woman with multiple and large uterine fibroids. During the pregnancy, there was adequate fetal development, without major maternal complicatio ns. Given the characteristics of the fibroids and breech position of the fetus, an elective caesarean section was decided, and postpartum hysterectomy planned. This challenging obstetrical case required a multidisciplinary approach. We considered crucial discussing five main issues: preconceptional counselling, tailored pregnancy surveillance, decision of time and route of delivery, decision to perform a peripartum hysterectomy and management of decreasing blood loss perioperatively. Given the limitation of the published reports, we believe that sharing our experience, along with a literature review, is beneficial for other clinicians. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Clozapine in the management of persistent destructive behaviour in a 17-year-old boy with intellectual disability

alkiviadis.1961 shared this article with you from Inoreader Clozapine in the management of persistent destructive behaviour in a 17-year-old boy with intellectual disability Via BMJ Case Reports Last 6 Issues The management of challenging and refractory destructive behaviour in young patients with intellectual disability (ID) is a major issue faced by families, carers and healthcare professionals who support them. Often, paediatricians and psychiatrists use various behavioural and psychopharmacological approaches, including polypharmacy. We report on one such patient who benefitted greatly from a trial of clozapine, resulting in less aggression, improved quality of life and pot entially huge cost savings. We conclude that clozapine may represent a beneficial though seldom-used option for severe, destructive behaviour in young people with ID. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Pneumopericardium and pleural effusion: a rare complication of paediatric pericardiocentesis

alkiviadis.1961 shared this article with you from Inoreader Pneumopericardium and pleural effusion: a rare complication of paediatric pericardiocentesis Via BMJ Case Reports Last 6 Issues Pneumopericardium is a rare complication of pericardiocentesis (PC), occurring as a result of either a direct pleuropericardial communication or a leaky drainage system. Pneumopericardium is often self-limiting; however, physicians should be aware of this complication as it may progress to tension pneumopericardium, which requires immediate recognition and management. PC has been associated with pneumothorax, pneumomediastinum or subcutaneous emphysema, but the association with pleural effusion has been less reported. The authors present the case of a 14-year-old healthy boy who developed post-PC pneumopericardium and pleural effusion, a rare association reported in the literature. The diagnosis of this potential life-threatening event was made using readily available complementary diagnostic methods, such as transthoracic echocardiography and chest X-ray. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Gestational breast cancer: current challenges in staging and treatment of breast cancer

alkiviadis.1961 shared this article with you from Inoreader Gestational breast cancer: current challenges in staging and treatment of breast cancer Via BMJ Case Reports Last 6 Issues Gestational breast cancer (GBC) is the most common form of invasive cancer in pregnancy and has unique challenges in both staging and treatment given the dual goal of appropriate cancer management and minimising the risk of fetal toxicity. A 38-year-old woman with no significant medical history and 21 weeks pregnant presented with a palpable right breast mass. She was diagnosed with human epidermal growth factor receptor 2-positive infiltrating ductal carcinoma with advance d disease. The patient underwent treatment; however, unfortunately, she passed away after developing devastating distant disease recurrence. We highlight both the challenges and current guidelines for management of GBC. Our goal is to discuss the current limitations of GBC management and the necessity of further investigation for safe novel imaging and treatment modalities for pregnant women. It is crucial to increase awareness across multiple subspecialities, as a multidisciplinary team is necessary for proper treatment of GBC. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum after upper gastrointestinal endoscopy

alkiviadis.1961 shared this article with you from Inoreader Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum after upper gastrointestinal endoscopy Via BMJ Case Reports Last 6 Issues Upper gastrointestinal (GI) endoscopies are performed for several reasons. The overuse of endoscopy has negative effects on the quality of healthcare and pressurises endoscopy services. It also results in the complications. These complications include pneumoperitoneum, pneumomediastinum and subcutaneous pneumomediastinum. However, it is worth noting that these complications rarely occur during endoscopy of the upper GI tract. These complications, when they occur, indicate perforation of the retroperitoneal space or peritoneal cavity. In this article, we discuss a case of pneumoperitoneum, pneumomediastinum and subcutaneous emphysema after upper GI endoscopy. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Spontaneous extrusion of a dexamethasone intravitreal implant (Ozurdex)

alkiviadis.1961 shared this article with you from Inoreader Spontaneous extrusion of a dexamethasone intravitreal implant (Ozurdex) Via BMJ Case Reports Last 6 Issues A 59-year-old man with diabetic macular oedema was treated with a dexamethasone intravitreal implant (Ozurdex) to his right eye. Immediately after injection, the implant was noted to have extruded into the perilimbal subconjunctival space. The remnants of the implant were expeditiously removed the following day to avoid corneal decompensation and permanent corneal oedema. Endothelial decompensation secondary to the migration of dexamethasone implants into the subconjunctiva l space or anterior chamber is a recognised complication of Ozurdex injection. The patient recovered well postoperatively with no further complications. He was planned for a new Ozurdex implant 1 month later. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Continuous acellular material accumulation in the anterior chamber associated with corneal endothelial changes

alkiviadis.1961 shared this article with you from Inoreader Continuous acellular material accumulation in the anterior chamber associated with corneal endothelial changes Via BMJ Case Reports Last 6 Issues This case series included two healthy adults who showed continuous production of acellular materials in the anterior chamber without inflammation. The materials were membrane-like in case 1 and amorphous in case 2; they gradually changed shape and location over several years. During follow-up, there were no changes in vision, the iris or the chamber angle. Anterior segment optical coherence tomography confirmed the attachment of the membrane to the corneal endothelium. Spec ular microscopy showed normal endothelial counting with reversal of the normal light/dark patterns that occasionally returned to normal appearances. Although acellular materials were observed unilaterally in both cases, abnormal endothelial images were noted in both eyes of case 1. Histopathological examinations demonstrated the absence of cellular components with negative immunostaining for collagen IV, vimentin and α-smooth muscle actin. Serial ophthalmic examinations and histopathological findings suggest that the production of acellular material was associated with alterations of the corneal endothelium. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Murine typhus mistaken for COVID-19 in a young man

alkiviadis.1961 shared this article with you from Inoreader Murine typhus mistaken for COVID-19 in a young man Via BMJ Case Reports Last 6 Issues Fever is a widely recognised presenting symptom of COVID-19. Consequently, other febrile illnesses may be difficult to distinguish from COVID-19—leading to delays in diagnosis and treatment. One such illness is murine typhus, a fleaborne illness with worldwide distribution caused by Rickettsia typhi. It often presents with fever, headache and myalgia, all of which have been commonly reported with COVID-19. Although the disease is usually mild with a good prognosis , there have been reports of severe illness and death. I present a case of murine typhus in a young male who had 2 weeks of headaches and daily fevers during the COVID-19 pandemic. He was ultimately tested for murine typhus when his occupation as a dog trainer was queried, and he experienced resolution of symptoms after treatment with doxycycline. During this pandemic, clinicians must be vigilant of other febrile illnesses whose symptoms overlap with COVID-19. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Early diagnosis of spontaneous heterotopic pregnancy successfully treated with laparoscopic surgery

alkiviadis.1961 shared this article with you from Inoreader Message: Celia Soares, Ana Maçães, Mariana Novais Veiga and Marta Osório Author affiliations Obstetrics and Gynecology, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal Correspondence to Dr Celia Soares; celia.cmsoares@gmail.com http://dx.doi.org/10.1136/bcr-2020-239423 Request Permissions Description An 18-year-old nulliparous woman presented to our emergency department with a history of severe hypogastric pain with vomiting for 2 days and unknown date of last menstrual period. The patient had no relevant medical history and she was not taking any medication, including ovulation inductors. On clinical examination, she was haemodynamically stable, reported pain on palpation of the left iliac fossa but had no rebound tenderness. Transvaginal ultrasound revealed an evolutive 6 weeks' gestational age intrauterine pregnancy (IUP; figure 1A) and a non-cystic extraovarian mass (58×35 mm; figure 1B,C) with surrounding fluid in the left adnexa (figure 1). Two corpus luteum cysts were seen, one in each ovary. The blood results were normal and the human chorionic gonadotropin levels were 15 797 mIU/mL. Figure 1 Download figure Open in new tab Download powerpoint Figure 1 Transvaginal ultrasound image of an evolutive 6 weeks' intrauterine pregnancy (A). Left ovary (23×10 mm) (B) and, next to it, a non-cystic heterogeneous mass (58×35 mm) (C) with moderate free fluid (D). A heterotopic pregnancy (HP) was suspected, so the patient was admitted. In the first hours of hospitalisation, despite remaining haemodynamically stable, the patient had worsening abdominal pain, presenting at this time point with rebound tenderness and anaemia (haemoglobin 102 g/L). Ultrasound reassessment revealed a moderate amount of free fluid, consistent with the acute blood loss noted in the dropping haemoglobin. An exploratory laparoscopy was performed and revealed a moderate haemoperitoneum, an open left fallopian tube in its distal portion, and a clot and trophoblastic tissue in the pouch of Douglas (figure 2). A left salpingectomy was carried out. The pathological examination confirmed the diagnosis of tubal ectopic pregnancy (EP). She was discharged on day 2. The remaining pregnancy was uneventful. The patient delivered a healthy live baby girl at 39 weeks by vaginal delivery following a spontaneous labour. Figure 2 Download figure Open in new tab Download powerpoint Figure 2 Left fallopian tube open at its distal portion with clot and trophoblastic tissue in the pouch of Douglas. HP is defined as the coexistence of at least two pregnancies in different implantation sites and its incidence in spontaneous pregnancies is estimated to be 1/30 000.1 Predisposing risk factors include previous history of EP, tubal surgery, pelvic inflammatory disease, use of an intrauterine device, in vitro fertilisation in the current pregnancy, in utero diethylstilbestrol exposure and smoking.2 3 The main symptoms of HP are abdominal pain, adnexal mass, peritoneal irritation and an enlarged uterus,1 which can mimic other gynaecological causes (miscarriage, EP, IUP with haemorrhagic corpus luteum and adnexal torsion) and non-gynaecological ones (appendicitis, cholecystitis, bowel obstruction or pancreatitis).4 Due to these unspecific clinical symptoms, the diagnosis of HP is often delayed and only made after a ruptured EP,1 which is associated with a considerable risk of maternal morbidity and mortality (0.50 per 100 000 live births).4 5 Despite its low sensitivity (33%) in the detection of HP, transvaginal ultrasound is the gold standard for diagnosis.6 7 Although ultrasound evaluation of an early gestation should include the adnexa, the diagnosis of an IUP often leads to the mistaken exclusion of the hypothesis of a concomitant EP.4 We present a rare case of a spontaneous HP in a woman with no obvious predisposing risk factors. Patients with no risk factors account for a minority of the cases of HP.3 Despite the low suspicion index, transvaginal ultrasound with systematic evaluation of the adnexa allowed an early diagnosis of such a rare case of HP. There are several cases reported of HP where EP was not detected initially.7 8 A key insight of the presented report is that careful adnexal ultrasound assessment mitigates the risk of missing an EP in the presence of an IUP. A timely diagnosis of HP offers more treatment options to patients. In the reported case, the patient underwent a laparoscopic salpingectomy. The uterus was not manipulated, to preserve the IUP. This is considered the safest treatment approach by most authors.5 7 Patient's perspective At first, I was very happy to know that I was pregnant as it was a desired pregnancy. I was far from imagining what was to come next. I never thought that from an emotional and physical point of view, it would be so painful. I had never experienced anything like this before in all my life. When it was told to me that I would have to undergo a surgical procedure, I was quite scared and somewhat afraid. From that moment on, I cannot remember anything. I must say that after waking up, I felt much better, without pain, but with some fear of what might still happen. Fortunately, everything went well and the pregnancy went smoothly. Despite the huge scare that was in the early hours, everything ended up going normal, and nowadays, fortunately, I have an extremely healthy, active child with no health problems or disabilities. Regarding the medical team in general, but particularly the team responsible for the operation, I would like to emphasise that they were extremely competent, attentive and especially very careful. I leave a huge thanks to everyone and I would also like to highlight the nurses and health assistants because they have had a fundamental role in my recovery. Learning points Heterotopic pregnancy (HP) is a life-threatening, difficult-to-diagnose condition. To exclude a possible ectopic pregnancy, it is important to evaluate the adnexa carefully through ultrasound, even if an intrauterine gestational sac is already confirmed and even if there is no apparent risk factor. HP tends to be overlooked after confirming an intrauterine pregnancy. When a diagnosis is established on time, the number of pregnancies that reach term after treatment is significant. References ↵Reece EA, Petrie RH, Sirmans MF, et al. Combined intrauterine and extrauterine gestations: a review. Am J Obstet Gynecol 1983;146:323–30.doi:10.1016/0002-9378(83)90755-Xpmid:http://www.ncbi.nlm.nih.gov/pubmed/6344638PubMedWeb of ScienceGoogle Scholar ↵Ankum WM, Mol BW, Van der Veen F, et al. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril 1996;65:1093.pmid:http://www.ncbi.nlm.nih.gov/pubmed/8641479CrossRefPubMedWeb of ScienceGoogle Scholar ↵Talbot K, Simpson R, Price N, et al. Heterotopic pregnancy. J Obstet Gynaecol 2011;31:7–12.doi:10.3109/01443615.2010.522749pmid:http://www.ncbi.nlm.nih.gov/pubmed/21280985CrossRefPubMedGoogle Scholar ↵Ramalho I, Ferreira I, Marques JP, et al. Live birth after treatment of a spontaneous ovarian heterotopic pregnancy: a case report. Case Rep Womens Health 2019;24:e00144. doi:10.1016/j.crwh.2019.e00144pmid:http://www.ncbi.nlm.nih.gov/pubmed/31709156PubMedGoogle Scholar ↵Eom JM, Choi JS, Ko JH, et al. Surgical and obstetric outcomes of laparoscopic management for women with heterotopic pregnancy. J Obstet Gynaecol Res 2013;39:1580–6.doi:10.1111/jog.12106pmid:http://www.ncbi.nlm.nih.gov/pubmed/23875926PubMedGoogle Scholar ↵Webster K, Eadon H, Fishburn S, et al. Ectopic pregnancy and miscarriage: diagnosis and initial management: summary of updated NICE guidance. BMJ 2019;367:l6283.doi:10.1136/bmj.l6283pmid:http://www.ncbi.nlm.nih.gov/pubmed/31722871FREE Full TextGoogle Scholar ↵Gibson KR, Horne AW. Ruptured heterotopic pregnancy: an unusual presentation of an uncommon clinical problem. BMJ Case Rep 2012;2012. doi:doi:10.1136/bcr-2012-007423. [Epub ahead of print: 28 Nov 2012].pmid:http://www.ncbi.nlm.nih.gov/pubmed/23192579Google Scholar ↵Fatema N, Al Badi MM, Rahman M, et al. Heterotopic pregnancy with natural conception; a rare event that is still being misdiagnosed: a case report. Clin Case Rep 2016;4:272–5.doi:10.1002/ccr3.502pmid:http://www.ncbi.nlm.nih.gov/pubmed/27014450PubMedGoogle Scholar Early diagnosis of spontaneous heterotopic pregnancy successfully treated with laparoscopic surgery Via BMJ Case Reports Last 6 Issues View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.