Tehran University Medical Journal

Background: Abnormal placental adhesion refers to abnormal placental implantation in which the anchoring placental villi attach to myometrium and even uterine serosa which may invade the bladder and bowels. One of the most important complications of these abnormalities is severe hemorrhage during placental removing which may even necessitate cesarean hysterectomy. Since uterine conservation is an important issue especially in young women at reproductive age, conservative management has a cardinal role to reduce bleeding during surgery. Uterine artery embolization as the first line conservative approach is reserved for women that fertility preservation is very important or whom the risk of severe bleeding during cesarean section is very high due to abnormal placental adhesion. Use of embolization in unstable patients is limited because it usually cannot be performed as rapidly as other measures. The aim of this study was to report two cases of uterine artery embolization before cesarean section in pregnant women with abnormal placental adhesions.
Case presentation: Two 35 and 37-year-old pregnant women at gestational age of 34 weeks diagnosed as placenta previa and abnormal placental adhesion (placenta percreta) who intended to preserve their fertility underwent bilateral uterine artery embolization before cesarean section in Ghaem hospital, Mashhad University of Medical Sciences, Iran at September 2016. Bleeding during surgery was significantly decreased and uterine preservation was successfully preformed without any serious complications during and after the surgery. In the next follow-ups, they had normal menstruation about two months after the cesarean section. 
Conclusion: In placental adhesive disorders, uterine artery embolization at the time of cesarean section could significantly decrease bleeding during surgery, so uterine and fertility preservation could be performed in this situation.
 

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: Laparoscopy is an acceptable procedure for cholecystitis in pregnancy. Laparoscopic complications during pregnancy can be unique. Uterine perforation is a rare complication during laparoscopy of pregnant women. Acquaintance with this complication can help surgeons and gynecologist to manage these patients properly. We will report a case of uterine perforation during laparoscopy.
Case presentation: Our patient was a 24-year pregnant woman with gestational age of 28 weeks. She had nausea and vomiting and right upper quadrant tenderness, she was admitted in surgery ward on January 2017 in an academic hospital in Mashhad and candidate for laparoscopic cholecystectomy with diagnosis of cholecystitis. Her fundal height was 28 centimeters. Laparoscopy was done with Hasson technique and three punctures. During abdominal trocar insertion uterine perforation occurred. Amniotic fluid leaked in the abdomen. Perforation repaired immediately and then cholecystectomy was done. Fetal heart rate was normal. After surgery according to stable vital signs and absence of bleeding and contraction, the patient was transferred to the midwifery department. The patient received one course of betamethasone for fetal lung maturation. Antibiotic therapy initiated. During the hospitalization, the patient was monitored daily for vital signs (fever and tachycardia), uterine contraction, vaginal bleeding and vaginal bleeding. Daily fetal heart monitoring was performed. After close prenatal care cesarean section was done in 38 weeks of pregnancy and a healthy baby was born with appropriate Apgar score.
Conclusion: Laparoscopy in pregnant women is usually safe. Pregnancy-specific complications such as uterine injury are not common, but with a series of precautions before and during surgery. These complications can be reduced. Uterine perforation during laparoscopy if properly managed is usually not associated with significant risk.

Background: Hydatid cyst is an endemic disease in Iran and many middle eastern countries. The clinical presentation of Echinococcus granulosus infection depends upon the site of the cysts and their size. Small and/or calcified cysts may remain asymptomatic indefinitely. However, symptoms due to mass effect within organs, obstruction of blood or lymphatic flow, or complications such as rupture or secondary bacterial infections can result. The most common involved organs with this parasite are the liver and lung. Unusual areas of the disease include breast, adrenal, appendix, peritoneum, omentum and mesenteric. The purpose of this study was to report a rare case of abdominal hydatid cyst with presentation of ovarian cyst in ultrasonography.
Case Presentation: A 26-year-old virgin woman with abdominal pain in the hypogastric region and lower and right quadrant of the abdomen, with gastric fullness and without nausea and vomiting referred to an emergent unit of Ghaem Hospital (an academic hospital of Mashhad University of Medical Sciences) in June 2017. In an ultrasound, a cyst of 95×105 mm in right adnexa of uterus was seen. Due to continued abdominal pain, laparotomy was performed for the patient. At the time of laparotomy, the ovaries, uterus and adnexa were completely normal. A 10×15 cm cyst was seen with a thin wall which adhering to the omentum and the small end of the stomach. Frozen section biopsy reported hydatid cyst.
Conclusion: Considering that hydatid cyst is endemic in Iran, the presence of cystic mass in the peritoneal cavity, hydatid cyst should be considered. To prevent complications and relapse, it is best to avoid cyst rupture during surgery as much as possible.

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.

Background: Differentiated thyroid cancer (DTC) frequently occurs in women at fertility age. One of the cornerstones in treating this malignancy is Radioactive Iodine (RAI) therapy following thyroid resection. In this study, we evaluated the effect of RAI therapy on the fertility rate and pregnancy complications.
Methods: This is a retrospective study on 41 patients with differentiated thyroid cancer, with at least one experience of pregnancy after standard treatment (thyroid resection followed by radioiodine therapy). All patients have been signed a written consent form in initial admission to our department. Furthermore, we asked our patients to fill in a questionnaire about their thyroid cancer and its treatment as well as pregnancy and its complication. As a control group with no different mean age, the same checklist has also been filled in for the patient’s healthy sister too, just related to gravidity and its complications. The complications of pregnancy were registered in these patients and compared with the control group consisted of their healthy sisters. Also, the association of abortion rate with other underlying factors has been assessed. All data has been included in SPSS software, version 22 (IBM SPSS, Armonk, NY, USA) and analyzed using logistic regression. This study conducted at the Nuclear Medicine Department of Ghaem Hospital in Mashhad, from May 2017 to February 2018 with the support of Mashhad University of Medical Sciences, Iran.
Results: No significant difference was noted in the mean age between case (differentiated thyroid cancer) and control groups (P=0.9). The two groups were also statistically similar in terms of pregnancy frequency (P=0.05) and number of alive children (P=0.8). Abortion seems to be the only item in DTC patients which was more than healthy sisters (0.2 versus 0.7) (P=0.003). However, this statistical difference showed no direct relationship with radioiodine treatment (RIT). As in DTC patients before and after RIT, no significant difference has been detected in DTC patients before and after RIT (P=0.48). Birth weight was not statistically different in DTC patients before and after RIT (P=0.66) and between DTC patients and their healthy sisters (P=0.2).
Conclusion: Radioiodine therapy for differentiated thyroid carcinoma has no considerable negative impact on pregnancy, whether on fertility rate or on gravity complications.

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: Sigmoid volvulus is a rare complication in pregnancy. The clinical presentation is similar to that of non-pregnant volvulus, although the symptoms can be masked by the enlarged uterus and physiological changes during pregnancy and it can be challenged and delayed in diagnosis and treatment. Delay in diagnosis can also lead to ischemia, necrosis and perforation of the intestine, which can have adverse maternal and fetal outcomes.
Case Presentation: A primigravid woman with gestational age of 31 weeks was admitted to a 3^rd level center with abdominal pain and abdominal distention. From the beginning of pregnancy, the patient complained of bloating and epigastric pain, And had used herbal medicine for defecation. The patient's constipation had worsened since six days before admission to the hospital. She had no vomiting and her general condition was good. Abdominal Supine X-rays were reported completely dilated sigmoid and she was treated with a possible diagnosis of ileus. Due to the progression of symptoms and abdominal distension, rectosigmoidoscopy was performed for her, and scattered mucosal erythema was seen. Discoloration of the purple mucosa was seen from a distance of about 35 cm from the annulus and the secretions inside the sigmoid lumen were seen as blood. Ischemic necrosis and sigmoid volvulus were strongly suggested for the patient and she was immediately transferred to the operating room. The abdomen was opened with a midline incision. A 30 weeks uterus was seen and sigmoid volvulus was confirmed. Detorsion and colostomy were done. Due to the unprepared intestine and the possibility of leakage from the site of anastomosis, sigmoidectomy was not performed. After 4 days, the patient was discharged in a good general condition and became a candidate for sigmoid colon resection after delivery.