Contributors EJW wrote the bulk of the letter, while the other authors aided with the formulation of ideas and proofreading. Patient consent for publication Not required.
The diagnosis of visceral perforation during pregnancy is often delayed and the management complex. A 32-year-old primigravid woman in her second trimester presented with abdominal pain and a pre-existing ileoanal pouch. Initial imaging was negative but later imaging was suggestive of serious pathology. At laparotomy, a caesarean section was performed. Peritonitis was encountered secondary to two discrete perforations in the small bowel separate from her pouch. Histology found an ischaemic perforation secondary to a pressure effect from the gravid uterus. In pregnancy, ileoanal pouches may make the interconnected bowel vulnerable to the pressure effect of the gravid uterus and perforation. Pregnant women with such a surgical history who develop symptoms suggestive of bowel perforation should have rapid imaging and their clinical team should consider early definitive surgical intervention.
Dear Editor, I found the discussion and proposals made by Manyonda et al. very interesting, particularly their consideration of the potential for using Estrogen-only Replacement Therapy (ERT) with an Levonorgestrel Intrauterine Device (LNG-IUD) to avoid the risks and side effects associated with progestogens used in Combined Hormone Replacement Therapy (cHRT). However, the author's concern with this option was that 'progestogen permeates into the blood stream' which may have an impact on breast cancer risk. They reported little research surrounding this, and the available studies referenced mainly examined premenopausal women. 1 A paper published by Buckner in 2019 examined the extent to which progestogens were seen in the plasma and cervical mucus, given the method of delivery. It showed that, with an LNG-IUD in situ, plasma concentrations were less than 1% of that found in cervical mucus. This compares to plasma concentrations being over 2000% of that found in the cervical mucus when progestogens are administered systemically. 2 This study suggests that an LNG-IUD could achieve the same endometrial protection with incomparably smaller plasma progestogen concentrations. Buckner's data confirms that some progestogen does permeate into the blood stream whilst using an LNG-IUD, and therefore the breast cancer risk would not be zero. However, it is important to acknowledge that this could be a significant reduction in risk compared to the alternative option of cHRT (with an increased risk of 24%). 3 Information from studies such as this may alleviate the worries of the authors regarding the magnitude of the risk associated with using an LNG-IUD.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.