Five cases of abnormality in twin pregnancies, detected by ultrasound examination during the second trimester, are reported. In four pregnancies there was a fetal malformation: discordant anencephaly, a monozygotic, heterokaryotypic twin pregnancy with coexistant Turner's syndrome and intrauterine death, concordant body stalk syndrome, and a dicephalus monster. In the other pregnancy one fetus dies in utero to become a fetus papyraceous, Four of the pregnancies were associated with raised levels of maternal serum a-fetoprotein, by singleton standards. Ultrasound examination proved of value in each case. Three pregnancies were terminated.
Haemorrhage from pelvic veins during obstetric and gynaecological surgery is a major cause of morbidity and mortality. In a recent commentary entitled The Seven Surgeons of King's: a fable by Aesop', surgeons from different specialties used techniques peculiar to their own practice to treat a woman with intractable haemorrhage. Could transcatheter arterial embolisation be the 'eighth surgeon'? We describe two cases where embolisation was used to control bleeding when local surgical measures had failed and discuss the use of embolisation in obstetrics and gynaecology. Case report 1A 35 year old woman underwent a Burch colposuspension. During the operation, after the sutures for the colposuspension had been placed, bleeding was seen to come from the right side of the pelvis. The sutures on the right side of the colposuspension were removed to investigate the bleeding. Attempts at controlling the bleeding with further sutures were unsuccessful and after two hours the pelvis was packed and the advice of an interventional radiologist was sought. Emergency balloon tamponade of both internal iliac arteries was carried out, and the woman was transferred to the angiography suite, still under general anaesthesia. Selective bilateral internal iliac arteriography showed there was extravasation of dye from the anterior division of the right internal iliac artery (Fig. 1). Gelfoam pledgets were injected until haemostasis was confirmed radiologically (Fig. 2) and then a metallic coil inserted. She was then transferred for 36 hours to the intensive care unit. Before extubation the following day the pelvic packs were removed. Her recovery was complicated by parasthesia and lack of power in her right leg, which has gradually improved. Nerve conduction studies suggested that this was neuropraxia and a full recovery is likely. Case report 2A 34 year primigravid woman was admitted to our hospital at 26 weeks of gestation with increasingly severe abdominal pain. Investigations, including magnetic resonance imaging, showed a mass measuring 12 cm in diameter in the rectovaginal pouch. While undergoing Correspondence: Dr K. Lingam, 3, Bourne Court, Commerce Street, Melbourne, Derbyshire DE73 lFT, UK. evaluation of this mass she collapsed with sign of intraabdominal haemorrhage. A laparotomy was performed when the peritoneal cavity was found to be full of blood. A classical caesarean section was carried out, a little boy weighing 1.06 kg being born. Only after the delivery was it possible to ascertain that the origin of the bleeding was spontaneous rupture of a left ovarian cyst. The cyst was impacted in the pelvis and bound to the side wall by adhesions. Attempts to remove the cyst provoked free bleeding. We consulted the interventional radiologist who successfully occluded both iliac arteries with balloon catheters. Angiography showed that the bleeding area was supplied by both internal iliac arteries which were successfully embolised by gelfoam. Postoperatively, there was evidence of continued intraabdominal haemorrhage, but this w...
Diagnosis of closed neural tube defects by ultrasound in second trimester of pregnancy By applying the techniques of maternal serum alpha-fetoprotein (AFP) screening and amniotic fluid AFP studies it is now possible to detect over 90% of open fetal neural tube defects1 2 early in the second trimester of pregnancy. Campbell3 has reported similar success rates in visualising both anencephaly and open spinal defects by ultrasound at this stage of pregnancy in "at risk" patients. In general, AFP studies do not identify fetuses with dosed defects, nor have there been any reports of the ultrasound diagnosis of such cases before 20 weeks. We describe two cases of closed defects diagnosed by ultrasound at 18 weeks. Case reportsCase I-A 27-year-old para 2 + 2 was referred because her first baby, who had died shortly after birth, had had a large open spinal defect. Her second child had been normal. In her current pregnancy an ultrasonic examination at 18 weeks showed appreciable widening of the normal cervical spinal echoes, and a well-defined 2-cm diameter cystic area "attached" to the lower occipital area and the upper cervical spine (figure). The biparietal diameter of the fetal head was within normal limits, and the ventricular echoes appeared normal, as did the remainder of the spine. The amniotic fluid AFP concentration was 8 mg/l, well within the normal range for 18 weeks.Section A shows a longitudinal scan of the fetus (case 1) along the spinal canal. At its upper end the canal is abnormally wide (Abn Sp). In B a cystic structure, the encephalocele (En), is seen attached to the lower occiput, and C shows the fetus after therapeutic abortion. The encephalocele, which ruptured during delivery, was completely covered by skin, as was the spinal canal.In view of the conflicting evidence of a neural tube defect, the ultrasonic scan was repeated and the previous findings were confirmed. After detailed counselling, the pregnancy was terminated. Examination of the aborted fetus showed a completely skin-covered occipital encephalocele. The cervical spine was abnormally wide and the laminae were of cartilagenous rather than bony tissue. The lower spine was normal.Case 2-A 31-year-old para 1 + 0 was referred at 18 weeks because her previous pregnancy had resulted in a mentally normal but severely physically handicapped child, whose abnormalities had included extensive spina bifida occulta, gross scoliosis, and unilateral absence of ribs. On the basis of several ultrasonic examinations a small low spinal defect and a large exomphalos were provisionally diagnosed. Two amniotic fluid AFP estimates were between the third and fourth SD levels respectively-that is, not in the range normally associated with an open neural tube defect. Because of the ultrasound findings and the existing burden of a handicapped child, the pregnancy was terminated. The presence of an exomphalos was confirmed and its intact sac found to contain the liver. No obvious lesion of the fetal back was seen but dissection showed spina bifida occulta of the lowe...
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