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Background: Posterior reversible leukoencephalopathy syndrome (PRLS) is a clinical and radiological syndrome of heterogeneous etiologies that are grouped because of the similar findings on neuroimaging studies which may occur at any age. The pathogenesis of RPLS remains unclear, but it appears to be related to disordered cerebral autoregulation and endothelial dysfunction. The syndrome is more commonly seen in women, RPLS has been described in several medical conditions, with hypertensive encephalopathy, eclampsia, and the use of cytotoxic and immunosuppressant drugs being the most common conditions. Prompt recognition and treatment are important in preventing the permanent damage that can occur in this otherwise typically reversible condition. The pathogenesis of RPLS remains unclear, but it appears to be related to disordered cerebral autoregulation and endothelial dysfunction. This report aimed to introduce a case of reversible posterior leukoencephalopathy following postpartum thrombotic thrombocytopenic purpura (TTP). Case presentation: The patient was a 30-year-old primigravid woman at 33 weeks of pregnancy who was referred to the Ghaem hospital, Mashhad University of Medical Sciences in Mashhad in July 2017 due to high blood pressure, blurred vision, headache and generalized tonic colonic seizure. She did not report in previous history of high blood pressure or seizure before pregnancy. With a diagnosis of eclampsia remote from delivery, she underwent a cesarean section. After delivery, generalized tonic colonic seizure repeated several times and a significant reduction in consciousness level happened. Renal failure also occurred, so she underwent daily plasmapheresis with a diagnosis of TTP. After 35 days, she was discharged with a good general condition. Conclusion: In predisposing conditions, such as high blood pressure in pregnancy, in the case of clinical suspicion of posterior leukoencephalopathy, any attempt for early diagnosis and appropriate treatment are important factors in reducing the rate of morbidity and mortality.

Background: Nephrotic syndrome is a kidney disorder that is identified by signs of nephrosis, severe proteinuria, hypoalbuminemia, and edema. It is a component of glomerulonephrosis, in which different degrees of proteinuria may occur. The complications of this syndrome may include blood clots, infections, and high blood pressure. Essentially, decreased protein through the kidneys (proteinuria) leads to low protein levels in the blood (hypoproteinemia including hypoalbuminemia), which causes water to be drawn into soft tissues (edema). Severe hypoalbuminemia may also lead to different secondary problems, including water in the abdominal cavity (ascites), around the heart or lung (pericardial effusion, pleural effusion), high cholesterol (hyperlipidemia) and, loss of molecules regulating coagulation (increased risk of thrombosis). Other symptoms may be weight gain, feeling tiredness, and also foamy urine. This study aimed to introduce a case of successful treatment of nephrotic syndrome in twin pregnancy. Case Presentation: The patient was a 30-years old woman who presented with twin pregnancy in 31 weeks of gestation with a history of IVF (In-Vitro Fertilization) in the current pregnancy. She referred to Ghaem hospital of Mashhad University of Medical Sciences in March 2017 because of severe lower extremities edema and 3+ proteinuria. Considering severe proteinuria (more than 6 gr/24 hr), edema, hypoalbuminemia and hyperlipidemia, the nephrotic syndrome was diagnosed and she was treated with methylprednisolone, Hydrochlorothiazide and Fenofibrate. At last, premature rupture of membrane occurred at 36 weeks of gestation. Cesarean was done because of the breech presentation of both fetuses and two healthy neonates were born with an optimal Apgar score. Conclusion: Early diagnosis of nephrotic syndrome and accurate prenatal care in these patients could have optimal pregnancy outcomes, especially if it was not complicated by hypertension and renal dysfunction.

Introduction: Uterine prolapse and bladder exstrophy (BE) during pregnancy is a rare condition. The aim of this study was to present a rare case of pregnancy which complicated by both the bladder exstrophy and uterine prolapse. Case presentation: A 39 year old pregnant woman (gravid 2, para 1) presented to the maternity department at 39 weeks of gestation with labor pain. Physical examination showed regular uterine contractions; the cervix was completely out of the vaginal opening with dilatation 3 cm and effacement 30%. She had the history of multiple surgeries for correction of bladder exstrophy and also suffered from uterine prolapse .In active labor, abnormal fetal heart rate tracing happened, so emergent cesarean section was planned and a healthy neonate with the normal Apgar score was born. At regular follow-up until 4 months after delivery, there was no sign or symptom of uterine proplase. Conclusion: Multidisciplinary management of patients with BE and uterine prolapse may result in the optimal perinatal outcomes. Uterine prolapse may disappear after delivery even in the complicated case of bladder exstrophy.

Background: Cervical pregnancy is a rare type of ectopic pregnancy (EP) in which the pregnancy implants in the lining of the endocervical canal. It accounts for less than 1 percent of ectopic pregnancies. The cause is unknown; local pathology related to previous cervical or uterine surgery may play a role given an apparent association with a prior history of curettage or cesarean delivery. The most common symptom of cervical pregnancy is vaginal bleeding, which is often profuse and painless. Lower abdominal pain or cramps occur in less than one-third of patients; pain without bleeding is rare. It is important to think about the possibility of cervical pregnancy in such patients since early diagnosis is critical to avoidance of complications and successful treatment. Management of this pregnancy is dependent on the hemodynamic status of the patient. Conservative management and some more aggressive therapy such as emergency hysterectomy can be used. The aim of this report was to introduce a case of successful conservative management of cervical pregnancy. Case presentation: A 30-year-old G2L1 woman with history of a previous cesarean section and possible diagnosis of missed abortion referred to the Gynecology Clinic of Ghaem Hospital, Mashhad University of Medical Sciences, Iran, in 21 May 2017. Cervical pregnancy was diagnosed during curettage. Severe hemorrhage occurred after curettage and the hemodynamic status of the patient was unstable immediately after curettage. Severe threatening vaginal bleeding was controlled with intrauterine Foley catheter containing 60 cc normal saline and then vaginal packing. The patient was discharged with good general condition. Conclusion: In cervical pregnancy and unstable hemodynamic status and desire to preserve fertility, intrauterine Foley catheter and vaginal packing after curettage is helpful.

Various methods are used in order to describe the heart rate patterns of the fetus. The use of electronic monitoring during labor is widely accepted today. The aim of this study was to compare the neonatal outcomes of continuous Fetal Heart Rate (FHR) monitoring to intermittent auscultation among low-risk pregnant women during labor. This randomized clinical trial was conducted among 900 low-risk pregnant women who met inclusion criteria and were admitted to maternity wards of academic hospitals of Mashhad University of Medical Sciences for labor. They were randomly divided into two groups: the intermittent auscultation group and the Continuous FHR monitoring group. The pregnancy and neonatal outcomes were compared in two groups; data were processed in SPSS16 software. P less than 0.05 was considered as significant level. In this study, the first and fifth minutes Apgar scores, the rate of NICU admission, advance resuscitation requirement, neonatal seizure incidence, and the neonatal or fetal death did not differ significantly between two groups (P>0.05). In the Continues monitoring group, the rate of cesarean section due to fetal distress and operative vaginal delivery was significantly higher rather than the other group (P=0.001). The results of this study showed that continuous FHR monitoring in low-risk pregnancies during labor increases the risk of cesarean and instrumental delivery without improving neonatal outcomes.

Background: Complete molar twin pregnancy with coexisting fetus is a rare and important diagnosis in obstetrics. Preeclampsia, preterm labor and life-threatening vaginal bleeding are the serious complications of this type of pregnancy. Gestational trophoblastic neoplasia should be ruled out after termination of pregnancy. In this study we reviewed a molar twin pregnancy with a live coexisting triple x fetus which has not been reported till now. Case Presentation: Our case was a 22-year-old primigravida woman and 17-18th week of pregnancy, who referred to an University Hospital in Mashhad, Iran with complaint of vaginal bleeding On October 2016. Her first trimester ultrasonography in 13th week of gestational age, reported a live single fetus with an anterior great placenta and cystic formation regarding molar pregnancy. According to above-report, Amniocentesis was done in 15th weeks of pregnancy and its result was triple X. After severe and life-threatening vaginal bleeding, she underwent an emergent hysterotomy. A fetus with no obvious anomaly and a great hydropic and vesicular placenta delivered. Episodic crisis of her blood pressure was best controlled with anti-hypertensive drugs. In our case, chemotherapy with methotrexate was started after poor decline of βHCG titration and definite diagnosis of gestational trophoblastic neoplasia. Remission was completely achieved after four courses of chemotherapy. Conclusion: Differentiation between complete molar pregnancy with live fetus and partial mole is always challenging in obstetrics. Serious complications as preeclampsia and severe vaginal bleeding may become life-threatening. Coexisting molar pregnancy should be ruled out in a pregnancy associated with frequent and unexpectant vaginal bleeding. Amniocentesis and an expert radiologist can help to differentiate them. Following these patients is very important to reveal any trophoblastic neoplasia.

Background: Late postpartum hemorrhage (PPH) is defined as uterine bleeding between 24 hours until 12 weeks after delivery. Uterine artery pseudoaneurysm is a rare cause of life-threatening late postpartum hemorrhage (PPH). Emergency uterine artery embolization (UAE) is an appropriate method for control of hemorrhage. The aim of this report was to present a case of uterine artery embolization in late postpartum hemorrhage due to uterine artery pseudoaneurysm. Case Presentation: A 25-year-old woman with the history of three previous cesarean sections was admitted 35 days after the last cesarean. She had severe vaginal bleeding for 35 days after cesarean section. Because of severe vaginal bleeding 35 days after cesarean section, the patient was at nearly shock state (BP=90.60 mmHg, positive tilt test, tachycardia PR=120/m). In speculum examination, she had severe vaginal bleeding, but there was no lesion in vagina or cervix, also, bimanual examination of the uterus and adnexal area were normal. She reanimated by two liters of normal saline and uterotonic agents (oxytocin and methergine) were administered. Laboratory data showed severe anemia (Hb=6.5 gr/dl), but coagulation tests were normal. Ultrasonography didn’t show any abnormality. Because of continuation of vaginal bleeding after stabilization of the patient, UAE was planned. During pelvic angiography, a pseudoaneurysm was diagnosed and then it was treated by successful UAE. Conclusion: Uterine artery embolization is a conservative management for control of late postpartum hemorrhage. It can be a useful and alternative method for uterine and hypogastric artery ligation and hysterectomy, therefore it has an important role in treatment and fertility preservation for young women.

Background: Herpes encephalitis is the most common cause of fatal encephalitis in the world which often presents with sudden fever, headache, seizure, focal neurologic symptoms, and consciousness loss. The aim of this study was to report a case of maternal death caused by herpes encephalitis which appropriate antibiotic therapy delayed because of early diagnosis of eclampsia. Case Presentation: A 16-year-old pregnant woman at 36th weeks of gestation was referred to gynecology emergency department of Ghaem Hospital, Mashhad University of Medical Sciences in 2016. She was admitted due to 4 times of generalized tonic-clonic seizures and blood pressure of 140/90 mmHg with diagnosis of eclampsia. Cesarean section was performed for fetal distress and eclampsia remote from delivery. 6 hours after cesarean section because of higher than 39 °C and reduction in consciousness status, she was transferred to intensive care unit (ICU). The first brain magnetic resonance imaging (MRI) was normal. Lumbar puncture (LP) was performed and brain MRI was repeated that increased signal was observed in two sides of basal ganglia. Intravenous acyclovir was administered by possible diagnosis of viral meningoencephalitis. Cerebrospinal fluid (CSF) was positive in terms of herpes simplex virus type 1 (HSV-1). Unfortunately, the patient died 35 days after hospitalization by diagnosis of HSV-1 encephalitis and bilateral infarction with frequent seizures and clinical manifestation of septic shock refractory to treatment. Conclusion: Although the first diagnosis for generalized convulsion during pregnancy is eclampsia, but in case of recurrent and specially atypical seizures and low consciousness level, other diagnosis like meningoencephalitis, brain lesions and cavernous sinus thrombosis (CVT) must be considered and ruled out.

Persistent low level of beta-hCG (PLL) is defined as rising hCG level no more than two-fold over a three months period. Almost many types of PLL can lead to the wrong diagnosis. Here, we presented two cases of the retained product of conception (RPOC) with persistent low levels of beta-hCG. Both cases were presented with persistent low levels of beta-hCG and abnormal uterine bleeding since first-trimester pregnancy termination. Ultrasonography revealed a vascular mass with extension from the endometrial cavity to myometrium imitating gestational trophoblastic disease (GTD) or arteriovenous malformation (AVM). The final pathologies of both cases were retained product of conception. Imaging features of RPOC can closely imitate those of an AVM or GTN; so, hysteroscopy is one of the best non-invasive procedures which may be helpful in diagnosis and selection of appropriate treatment especially in young patients who desire to preserve their fertility.

Objective: To evaluate the maternal and neonatal complications of vaginal birth after cesarean section (VBAC). Materials and methods: This cross sectional study was conducted in Mashhad University of medical sciences. Eighty women with previous cesarean section who were candidate for VBAC were enrolled the study. Patients were followed up for 6 weeks after delivery. The complication of VBAC was compared between successful or unsuccessful VBAC cases. Data was analyzed by SPSS version 16. Results: VBAC success rate was 91%. Post-partumhemorrhage occurred in 2.7% of woman with successful VBAC and 1.3% of CS cases. Maternal and neonatal death did not happen during our study, and none of our cases experienced uterine rupture, dystocia and neonatal tachypnea. Neonatal complications include NICU admission and neonatal resuscitation frequency in VBAC and CS were 6.8% and 57.1%, respectively (p = 0.002). Birth weight of neonates in successful VBAC was 2940 ± 768 grams and 3764 ± 254 grams in unsuccessful VBAC and this difference was significant (p = 0.007). Mean maternal admission duration in VBAC and CS were 1 ± 0.1 days and 2 ± 0.4 days (p < 0.001). Successful breastfeeding rate were higher in VBAC patients (95.8%) in comparison with CS (42.9%) and this difference was statistically significant (p = 0.002). Conclusion: Our results revealed that VBAC can be considered as a safe maternal and neonatal delivery method in patients with past CS women.

Background: Twin pregnancy with a fetus and a diploid complete mole is not rare, but, the cases of twin pregnancy with a partial mole are rare. Nowadays, the prevalence of these cases has been increased due to the high rate of assisted reproductive techniques in reproductive medicine. The importance of twin pregnancy with a fetus and a diploid complete mole is mainly due to systemic complications such as hypertension and maternal hemorrhage and the possibility of trophoblastic tumor following delivery. Different studies have reported some results about similar cases, but limited case reports are presented in our country. The aim of this study is to report a case with incomplete molar pregnancy concomitant with a live fetus. Case presentation: A 21 yr old woman (G2 ab1) referred to emergency department of Ghaem University Hospital in Mashhad. She complained of scant vaginal bleeding and spotting and a sonography report of a combined molar and normal pregnancy with 15 weeks gestational aged. During hospitalization, the pregnancy complicated with hypertension and proteinuria. Termination of pregnancy was planned at 17th weeks of gestation due to severe preeclampsia. After evacuation of uterus, during follow up visits, -hCG titer raised. Metastasis evaluation was negative. Pathology reports showed patial mole. Then, three doses of methotrexate (50 mg/m2 intra muscular) was administered and finally, according to the monthly follow up, -hCG level was undetectable. Conclusion: The rate of pregnancy complications such as hypertension, hyperthyroidism, and obstetrics hemorrhage and also the risk of Gestational Trophoblastic Neoplasm (GTN) are increasing in incomplete molar pregnancy. Therefore, early diagnosis and timely treatment of molar pregnancy is very important to reduce maternal morbidity and mortality.

Background: Placenta accreta is a life-threatening complication after previous cesarean delivery. The aim of this case report is to present a case of placenta percreta with bladder involvement and subsequent maternal death.Case presentation: The patient was a 37-year old who had an unwanted pregnancy due to tubectomy failure two years afterwards. She was hospitalized at 26th and 30th week of gestation because of gross hematuria. Sonography reported placenta previa. Cesarean section was performed at 34th gestational week. Due to severe hemorrhage, hysterectomy with resection of some part of the bladder was done. Died at the operating room after four hours of severe uncontrollable hemorrhage. Conclusion: The increasing prevalence of different forms of placenta accreta is the result of the ever-increasing rate of cesarean deliveries. One of the strategies to prevent this catastrophic obstetric complication is decreasing the number of cesarean deliveries without appropriate indications.

Introduction: Wernicke’s Korsakoff syndrome is the most important complication of severe thiamine deficiency. Confusion and gait ataxia are the most prevalent symptoms, respectively. The aim of this study was report of a case of Wernicke’s encephalopathy following hyperemesis gravidarum. Case report: A 28-years-old pregnant woman in 19th weeks of gestation referred to the hospital with hyperemesis, gait ataxia, and dysarthria. MRI showed hyperdense lesion which was characteristic of wernicke’s encephalopathy. Rapid improvement in patient’s condition occurred after thiamine infusion. Conclusion: In hyperemesis gravidarum, presence of either symptoms of ocular or mental disorder or ataxia must be considered to rull out Wernicke’s syndrome which can cause maternal death.