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Background: Vulvar hematoma is a relatively uncommon occurrence. Most have been described resulting from traumatic injury in nonpregnant women or as an uncommon complication of childbirth. We describe a case of a spontaneous 6-cm vulvar hematoma that presented as unexplained vulvar edema in a 35-weeks-pregnant woman., Case: A pregnant woman presented to the obstetrics triage unit with rapid onset unilateral vulvar swelling and no preceding traumatic event. A detailed physical examination and radiologic evaluation revealed a spontaneous vulvar hematoma as the cause. After incision and drainage of the hematoma, her edema resolved and the patient went on to have an uneventful vaginal delivery 4 weeks later., Conclusion: Spontaneous vulvar hematoma is a rare event. Rapid recognition and treatment in this case allowed for complete recovery and enabled this pregnant woman to continue a normal pregnancy with uncomplicated spontaneous vaginal delivery.

Background: Uterine prolapse in pregnancy is rare and can either occur during pregnancy or be present before the pregnancy. We present a case of a successful pregnancy in a patient with preexisting uterine procidentia., Case: A 44-year-old woman with a history of complete uterine prolapse presented with an unplanned pregnancy. Upon initial presentation at 15 weeks she had uterine prolapse with cervical elongation that protruded 10 cm past the introitus. The prolapse persisted until about 30 weeks, during which it was conservatively managed with bed rest, knee-chest positions and local treatment of the desiccated cervix with emollients. The patient had an uncomplicated vaginal delivery and underwent a vaginal hysterectomy, anterior-posterior repair and a sacrospinous ligament fixation a few months later., Conclusion: Uterine prolapse in pregnant women with preexisting prolapse will probably resolve in the third trimester without treatment. An otherwise uncomplicated course and a vaginal delivery can be expected.

Objective: To determine the frequency of anorectal complaints in nulliparous, pregnant women before and after delivery., Study Design: This was a prospective, observational study. Nulliparous, pregnant women attending an active-duty prenatal clinic completed a 6-item anorectal symptom questionnaire that assessed anal continence and defecatory symptoms., Results: Seventy-five active-duty, nulliparous women completed 158 questionnaires. Anorectal symptoms were reported both antepartum (AP) and postpartum (PP): straining to defecate (AP: 28-59%; PP: 30%), hard or lumpy stools (AP: 48-59%; PP: 66%), incomplete emptying (AP: 38-53%; PP: 38%), uncontrolled loss of gas or stool from the rectum (AP: 18-29%; PP: 15%), unpreventable soilage of underwear (AP: 15-33%; PP: 13%) and splinting (AP: 3-9%; PP: 9%). Constipation symptoms were reported most frequently in the first trimester (p = 0.031) and anal incontinence most often in the third trimester but loss of gas or stool "often" more in the postpartum period (p = 0.027). Anal incontinence was more frequent in women who delivered by forceps (p = 0.007)., Conclusion: Anorectal symptoms are common both during pregnancy and in the postpartum period. Anal incontinence is reported more frequently in women who delivered by forceps.

Background: Isolated fallopian tube torsion during pregnancy is a rare condition, and only 16 cases have been reported. In all but 1 case the right tube was affected. We report the second case of isolated left fallopian tube torsion during pregnancy., Case: A 23-year-old primigravida presented at 22 weeks of gestation with left lower abdominal pain. Sonography depicted a simple cystic mass adjacent to the left uterine border. Laparotomy revealed torsion of the left hydrosalpinx together with a paraovarian cyst. The patient delivered a healthy infant at term after an otherwise-uneventful pregnancy., Conclusion: As the gravid uterus increases the risk for fallopian tube torsion, this condition should be included in the differential diagnosis of lower abdominal pain during pregnancy.

Background: Spontaneous rupture of uterine vessels during pregnancy is rare and usually involves uteroovarian veins. Presenting symptoms include acute-onset abdominal pain and maternal hypovolemic collapse due to hemoperitoneum. An atypical case of subacute uterine artery rupture at 27 weeks of gestation occurred in a woman with sickle cell disease., Case: A 28-year-old, nulliparous woman with sickle cell disease was admitted at 27 weeks of gestation for sharp abdominal pain radiating to the right flank. The first diagnosis included acute renal colic and a sickling vasoocclusive crisis. One week after admission the patient experienced paroxysmal, diffuse abdominal pain associated with acute fetal distress requiring an emergency cesarean section. Laparotomy revealed an 800-mL hemoperitoneum. Active bleeding from a ruptured uterine artery was observed and successfully treated by selective suture., Conclusion: Spontaneous rupture of the uterine artery during pregnancy may present as a 2-step process.

Background: Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is the most common dermatosis of pregnancy. It usually evolves in the third trimester and resolves rapidly postpartum., Case: A 25-year-old woman complained of an intensely pruritic rash for 2 days. The rash began 10 days postpartum. It began on her abdomen and spread to her buttocks, legs and upper arms. On examination, erythematous papules and urticarial plaques were present in the striae of the abdomen and buttocks and involved the legs, arms and back. No excoriations, vesicles or pustules were present, and there was sparing of the face, palms and soles. The patient was treated with fexofenadine, hydroxyzine, oatmeal baths and cool compresses. Follow-up 2 days later revealed a worsening rash and persistence of severe pruritus. At that time the patient was placed on prednisone, which led to relief of her symptoms and clearing of the rash., Discussion: PUPPP is reported to develop in 0.5% of pregnancies. MEDLINE searches of the literature from 1966 to 2003 using the keywords pruritic urticarial papules and plaques of pregnancy or polymorphic eruption of pregnancy and postpartum revealed only 2 other cases of PUPPP developing in the postpartum period. Although the clinical presentation of this patient was typical of that of PUPPP, it demonstrates an unusual time course with its postpartum presentation., Conclusion: Dermatoses of pregnancy should remain in the differential diagnosis of rash even weeks after a woman delivers.

Background: Laparoscopic surgery in the second trimester is very rare. The enlarging uterus impedes surgical procedures and increases the risk of surgery. We report on a woman in the 27th week of pregnancy who developed a huge ovarian tumor., Case: A woman underwent laparoscopic surgery in the 27th week of gestation because of a rapid growing ovarian tumor. After aspiration of its contents, the tumor was extracted, and cystectomy was performed extracorporeally. The postoperative course was uneventful and the woman delivered a healthy infant at 42 weeks., Conclusion: Laparoscopic gynecologic surgery can be performed through the 27th week of gestation, and extracorporeal manipulation makes the procedure much easier.

Objective: To assess long-term outcome in women treated for vulvar dysesthesia (vulvodynia)., Study Design: Cross-sectional survey via mailed questionnaires of women with vulvar dysesthesia treated at the University of Michigan. Questionnaires addressed symptom characteristics and their predictors, pregnancy response and treatments used. Analysis included t tests, nonparametric tests and multivariate analyses to assess associations between the degree of improvement (in the amount of pain experienced) since diagnosis and potential predictors of that outcome., Results: Of 234 questionnaires mailed, 104 were completed. Based on a 7-point pain scale (0-6, with 6 indicating excruciating pain), the level of pain at the time of the survey (1.6 +/- 1.3) was significantly lower than that at the time of diagnosis (4.5 +/- 1.5) (P < .0001). Of the 104 women, 56.8% reported > 50% improvement in their pain since diagnosis, and the pain had worsened in 1.9%. Greater improvement was noted with higher pain levels at baseline and with a shorter time since onset. The majority of women who had been pregnant since developing vulvar pain reported improvement (30%) or no change (40%) in symptoms during and after pregnancy. Treatments (nonrandom) rated as most effective included antidepressants (used for pain control) and anticonvulsant medications, biofeedback and counseling., Conclusion: Most women with vulvar dysesthesia reported markedly less pain at follow-up, although few reported a "cure." Pregnancy was not associated with worsening of vulvar symptoms for most women. Controlled clinical trials will be needed to elucidate treatments that are most effective.

Background: Choledochal cyst is rarely diagnosed during pregnancy, and it is very difficult to make a diagnosis of it clinically or radiologically., Case: A woman was diagnosed as having an ovarian cyst and gallbladder mucocele on ultrasonography in both her first and second pregnancies. She was asymptomatic, and conservative management was adopted. Three days after delivery of her second child, the patient had a sudden onset of right upper quadrant pain associated with deranged liver function. Emergency laparotomy revealed a type I choledochal cyst with evidence of infection. Excision of the cyst, cholecystectomy and bilateral hepatojejunostomy in the Roux-en-Y fashion were performed., Conclusion: A choledochal cyst in pregnancy is difficult to diagnose and poses a threat to mother and fetus.

Background: Gallbladder torsion is rarely diagnosed in pregnancy, but prompt surgical intervention is necessary to avoid possible sepsis and death., Case: A 28-year-old, African American woman at 30(6/7) weeks' gestation was admitted with the presumed diagnosis of acute cholecystitis. The patient was treated conservatively. However, on re-examination, the patient's physical examination and laboratory values worsened. She underwent an exploratory laparotomy, which revealed a twisted gallbladder. A cholecystectomy was performed after untwisting of the gallbladder. Postoperatively the patient did well and subsequently delivered a healthy infant at 38(2/7) weeks' gestation., Conclusion: Surgical evaluation of an acute abdomen in pregnancy should not be delayed. For a presumed diagnosis of acute cholecystitis that does not improve after conservative measures are taken, gallbladder torsion should be added to the differential diagnosis.

Background: Gigantomastia during pregnancy is exceedingly rare, with an incidence of 1/28,000-100,000 pregnancies. Treatment during pregnancy is a dilemma, and postpartum reduction mammoplasty remains the mainstay of treatment., Case: Massive bilateral breast enlargement occurred at 19 weeks of gestation in a 24-year-old woman, gravida 2, and led to ulceration and sloughing. Conservative management with bromocriptine resulted in healing of the ulcers and resolution of symptoms. After six months of bromocriptine therapy postpartum, marked involution of the breasts occurred without recurrence., Conclusion: Prolonged bromocriptine therapy should be given after delivery to a pregnant woman with gigantomastia during pregnancy before planning surgical reduction mammoplasty.

Objective: To determine if fetal membranes might be one of the sources of Fas and Fas ligand in amniotic fluid., Study Design: Human fetal membranes from elective cesarean section (n = 6) were fixed in paraformaldehyde. Rolls of paraffinembedded fetal membranes were cut into 5-micron sections. After blocking with horse and goat sera, sections were incubated overnight with primary antibodies followed by the appropriate secondary antibodies. Avidin-biotin complex and diaminobenzidine were used for immunoperoxidase localization. Expression of Fas and Fas ligand was read by light microscopy., Results: Both Fas and Fas ligand were localized in amnion, chorion and decidual layers. In amnion, Fas and Fas ligand were expressed predominantly in epithelial cells and fibroblasts, while there was no immunostaining in the subepithelial compact connective tissue. In the chorion, the expression was mainly in the chorionic trophoblast, with inconsistent expression in the reticular layer. In the decidua, the expression of Fas and Fas ligand was less prominent than in amnion and chorion., Conclusion: Localization of Fas and Fas ligand in human fetal membranes suggests that fetal membranes could be one of the sources of soluble Fas and Fas ligand in amniotic fluid.

Background: Acute fatty liver of pregnancy is a rare entity. A MEDLINE English-language search from 1966 to the present revealed no reports of acetaminophen toxicity and acute fatty liver in pregnancy., Case: An 18-year-old, African American woman, gravida 1, presented at 33 weeks' gestation with signs and symptoms consistent with acute fatty liver of pregnancy and fetal death. Markedly elevated transaminases prompted a search for other etiologies, and acetaminophen toxicity was diagnosed. Liver biopsy revealed acute fatty liver of pregnancy and toxin-induced injury consistent with acetaminophen use. The patient's condition deteriorated, resulting in fulminant hepatic failure and requiring postpartum orthotopic liver transplantation., Conclusion: The combination of acute fatty liver of pregnancy and acetaminophen toxicity resulted in acute liver failure. Attention to clinical and biochemical parameters can lead to diagnosis and management.

Background: Recent studies have noted a striking similarity between amniotic fluid embolism (AFE) and anaphylaxis. Serum tryptase levels may therefore serve as a marker of mast cell degranulation in AFE cases., Case: A 40-year-old woman, gravida 6, para 4, experienced the acute onset of facial erythema, eclampsia-type seizures, severe hypoxia, cardiac arrest and disseminated intravascular coagulation while in early active labor. The patient was declared dead 37 minutes after the onset of resuscitative efforts. At autopsy, fetal squames were found within the pulmonary tree, uterine blood vessels and brain. A peripheral venous blood specimen, obtained approximately one and a half hours postmortem, revealed a tryptase level of 4.7 ng/mL (normal, < 1)., Conclusion: An elevated serum tryptase level, in conjunction with our patient's clinical history, adds further supporting evidence to the concept of AFE as an anaphylactoid syndrome of pregnancy.

Objective: To describe the antenatal complications, mode of delivery and outcome of pregnancy in women with spina bifida., Study Design: Case series of women known to have attended the spina bifida clinic at the Royal Children's Hospital. Medical records, postal questionnaire and telephone interview were utilized to collect data on the effect of pregnancy on the health of women and the effect of spina bifida on pregnancy outcome., Results: Of 207 women born between 1945 and 1975, 23 reported having a pregnancy, and 17 who had completed pregnancies agreed to participate. The 17 women had a total of 29 pregnancies, with 23 pregnancies progressing to births. Fourteen of 17 women had antenatal admissions, with wheelchair-dependent women requiring more-frequent and longer admissions. Recurrent urinary infections in pregnancy occurred in women with a prior history of urinary infections; stomal problems occurred but were not serious; mobility was reduced for two women during pregnancy, with full recovery afterwards; and preexisting pressure sores worsened during pregnancy. Vaginal deliveries occurred in one in five pregnancies of women who were wheelchair dependent and in ten of eighteen pregnancies in independently mobile women, including seven of eight pregnancies of independently mobile women without ileal conduits. Cesarean sections were accompanied by postoperative complications in 10 women., Conclusion: Women with spina bifida who become pregnant generally have a positive outcome, with relatively low complication rates.

Background: Sarcoidosis is a multiorgan-system granulomatous disease causing respiratory complaints in most patients. Eye involvement, most commonly granulomatous uveitis, is seen in 5% of black patients with sarcoidosis. Neurosarcoidosis is also rare, affecting 5% of patients with sarcoidosis. Thoracoscopic lymph node biopsy in pregnancy has never before been reported., Case: An otherwise-healthy, 25-year-old woman, gravida 2, para 1001, presented at 25 weeks' gestation with a painful facial palsy and visual defects. Ophthalmologic examination revealed uveitis, and a chest radiograph revealed asymmetric hilar adenopathy. At 28 weeks' gestation, the patient underwent thoracoscopic lymph node biopsy, which confirmed the diagnosis of sarcoidosis. The symptoms were stabilized with therapeutic corticosteroids, and the patient delivered a healthy neonate at term., Conclusion: The diagnosis of sarcoidosis remains one of exclusion and requires a high index of suspicion. Tissue confirmation is often necessary, especially when patients have extrathoracic complaints. For patients without other lesions amenable to biopsy, thoracoscopic lymph node biopsy can be considered despite pregnancy.

Background: Twin gestation in a uterus didelphys is a rare condition, and the preferred labor course for these patients is unclear., Case: A woman with a uterus didelphys presented at 14 weeks' gestational age. Serial ultrasound examinations demonstrated normally growing, diamniotic, dichorionic twins situated one in each uterine horn. The prenatal course was marked by intrauterine growth retardation, elevated liver functions and significant proteinuria. At 31 weeks' gestation, labor was induced; however, due to chorioamnionitis and arrest of cervical dilatation, cesarean section was performed 23 hours after rupture of membranes, and two viable female infants (1,480 and 1,421 g) were delivered., Conclusion: Twin gestation in a uterus didelphys is a rare condition, in which a trial of labor may be offered, with careful monitoring of both fetuses.

Background: Hyperreactio luteinalis rarely occurs in normal singleton pregnancy. About 50 such cases have been published. This case is noteworthy because it resulted in extremely enlarged ovaries and was accompanied by a hyperandrogenic state and high level of human chorionic gonadotropin., Case: A gravida was referred to our department because of large, bilateral, cystic ovaries diagnosed by ultrasonography in the 28th week of gestation. Markedly elevated levels of androgens and human chorionic gonadotropin were noted. During the following six weeks the ovarian masses enlarged, and the hyperandrogenic state worsened. Cesarean section and, because of a bleeding right adnexectomy, left ovarian resection were performed. Histology confirmed the presumed diagnosis of hyperreactio luteinalis. The placenta was unremarkable. Seventeen weeks after surgery the hormone levels were normal., Conclusion: Our case suggests the possibility that in certain cases of hyperreactio luteinalis, an idiopathic elevation of human chorionic gonadotropin, can occur even in normal singleton pregnancies. Furthermore, it calls attention to the necessity of ultrasonographic demonstration of ovaries even during late pregnancy.

Objective: To comprehensively review causes of recurrent pregnancy loss and the currently applied methodologies for their diagnosis and management., Study Design: A review article addressing pertinent issues on the subject of recurrent pregnancy loss, which, by definition, is three consecutive pregnancy losses prior to the 20th week of gestation., Results and Conclusion: Diagnostic workup and treatment of recurrent abortion often poses a special challenge as numerous conclusive and nonconclusive causes have been described with varied and often controversial approaches for their management. While a definitive cause may not be discovered in a significant number of cases, among those with an identifiable cause, anatomic disorders are by far the most conclusively diagnosable and effectively treatable conditions, making their exclusion or inclusion an essential part of the evaluation. That up to 60% of these cases may achieve successful pregnancy without any intervention should receive serious consideration when analyzing results of studies that claim therapeutic benefits from treatment modalities.

Objective: To present a review of our experience and that of the medical literature in the diagnosis and management of oral pregnancy tumor (pyogenic granuloma), the natural History of the disease, its hormonal etiology, histopathologic features and management strategies., Study Design: Medical literature review., Results: This common, benign, hyperplastic oral mucosal lesion is much less familiar to gynecologists and obstetricians than to dentists., Conclusion: For practitioners engaged in primary care obstetrics and gynecology, routine oral examination and proper identification of pyogenic granuloma are important to avoid misdiagnosis and overtreatment.

A 23-year-old woman who presented in the 17th week of her third intrauterine pregnancy was diagnosed as having active Wegener's granulomatosis. Therapy, consisting of corticosteroids, cyclophosphamide and hemodialysis, was instituted and maintained until delivery. Although Wegener's granulomatosis complicated by pregnancy has been reported previously, this is the first reported patient to be treated successfully with the above agents during the second and third trimesters without apparent harm to her or her infant.

Hip pain in late pregnancy is quite common, and its etiology is rarely established unless acute demineralization occurs. We measured the bone mineral content of both hips in 26 women within 48 hours of delivery. Twelve of 36 densities (33%) were decreased in a group with severe pain when compared to 12 of 120 decreased densities (10%) in the remaining patients (P less than .05). Those data suggest that severe hip pain may be related to a decrease in bone mineral content.

Acute fatty liver of pregnancy is associated with complications that can influence antepartum management and necessitate delivery. To date, liver biopsy has been regarded as the "gold standard" for diagnosis. Radiologic evaluation of the liver has been suggested as a less invasive means of diagnosing this entity. Five patients with acute fatty liver of pregnancy underwent ultrasonography; three underwent concomitant computed tomography (CT) of the liver. The liver appeared to be normal in all the patients undergoing CT evaluation and all undergoing ultrasonography except one. Normal liver examinations are not unusual findings in patients with acute fatty liver of pregnancy.

To clarify the characteristics of dysplasia in the pregnant state, 525 of 703 dysplasias in pregnant women recorded in the laboratory computer at the University of Chicago Lying-in Hospital during a ten-year period were selected for study through medical records. These materials were basically diagnosed by cytologic techniques. The regression rates of moderate and marked dysplasia within a six-month period after delivery seemed to be much higher than those of dysplasia in the general population. The progression rates of dysplasia to carcinoma in situ during pregnancy and after delivery were almost the same as those of dysplasia in the nonpregnant state, whereas the progression rate of dysplasia to invasive carcinoma after delivery (0.4%) was almost half that in the nonpregnant state (1%). With reference to the latent period during which dysplasia progressed to malignancy, dysplastic lesions during pregnancy, as compared to those in nongravid women, had a higher potential for progression. The number of dysplastic cells decreased with the course of pregnancy. The rates of metaplastic and keratinizing types of dysplasia were remarkably higher than those in the general population, and the rates of those types of dysplasias increased with the course of pregnancy.

Two cases of tetracycline-associated fatty liver of pregnancy are reported. In one, the history was negative for antibiotic use, yet autopsy revealed typical gross and microscopic bone fluorescence of tetracycline. Tissue extraction and chemical analysis showed qualitative evidence of tetracycline, whereas quantitation revealed 60 microgram/gm of wet bone tissue. Findings in our cases and in those from the literature indicate that the association of tetracycline use and fatty liver of pregnancy is even more common than has been suggested.

A patient is presented with hemangioma of the ovary complicating the third trimester of pregnancy. The discovery of this tumor during pregnancy has not been reported previously. The topic of ovarian hemangiomas and the difficulty associated with ovarian pathology during pregnancy are reviewed briefly.

Endometriosis retards the process of conception, but conception does not retard the progression of this disease. When a series of patients with endometriosis after pregnancy were examined, sites of endometriotic involvement and presenting symptoms appeared unchanged. It seems that the effect of pregnancy on this disease is only temporary.

A working model for the histogenesis of carcinoma of the uterine cervix is summarized in Table I. The inclusion of squamous metaplasia in this chart does not imply that this reaction falls into the spectrum of cervical neoplasia or is necessarily an antecedent to neoplasia. It does simply imply that the carcinogenic event or events apparently occur in or involve an epithelium that is indistinguishable from squamous metaplasia. The chart intentionally implies that the lesions mentioned are not separate diseases but arbitrary points in the spectrum of cervical neoplasia. It must be emphasized that one stage does not necessarily progress to the next and that at any stage up to indisputable cancer the changes may regress, persist or progress. The careful evaluation of histologic material from the uterine cervix will permit the pathologist to exclude those epithelial abnormalities which are not a part of the spectrum of cervical neoplasia and allow him or her to place the patient with cervical neoplasia at the proper stage in the development of the process. With this information the clinician can then intelligently plan appropriate therapy.

A 30-year-old woman developed pruritic urticarial papules and plaques of pregnancy (PUPPP). The eruption, characterized by generalized edematous, erythematous plaques and nonexcoriated papules, began in the third trimester of pregnancy and was responsive to oral corticosteroids. While the etiology of PUPPP is unknown and the clinical features (urticarial plaques) sometimes overlap with those of other dermatoses of pregnancy, we regard PUPPP as a distinct entity. Utilization of a broad base of clinicopathologic and laboratory criteria is important in the workup of a patient with an eruption of pregnancy.

A 23-year-old woman presented with primary hypothyroidism and inability to lactate following uneventful childbirth. Endocrine evaluation revealed that she had autoimmune hypothyroidism and deficiencies of ACTH and prolactin. Despite partial hypopituitarism, she again conceived spontaneously, had an uneventful pregnancy and delivery but failed to lactate. Radiologic evaluation of the hypophysis, including CAT scan, was normal, and antibodies to anterior pituitary cells were not detected. The etiology of the pituitary insufficiency might have been autoimmune hypophysitis , a recently described entity in which anterior pituitary, along with the other endocrine glands, is destroyed by an autoimmune process. The clinical course suggested that women with pituitary insufficiency, although rare, are able to conceive and carry the pregnancy to term. Our patient illustrates that prolactin insufficiency does not preclude a successful outcome of pregnancy but can result in no lactation.