Tehran University Medical Journal

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cBackground: Choriocarcinoma is a highly malignant form of gestational trophoblastic disease. It is characterized by metastatic potential, rapid growth and deeply invasion into blood vessel and then widespread dissemination metastasis. However, the most common sites of metastatic choriocarcinoma are lung, vagina, liver, and brain. But, metastatic choriocarcinomas rarely is extended to gastrointestinal system. It is im-portant to keep in mind that despite extensive metastasis, choriocarcinoma is very curable disease. Due to high responsibility of this disease, early diagnosis of choriocarcinoma and treatment with chemotherapy can prevent mortality and morbidity of these patients. In this case report, we present a rare case of metastatic choriocarcinoma in the small bowel after normal term pregnancy. Case Presentation: A 34-years-old woman G4, P4, L4 presented with abnormal postpar-tum vaginal bleeding (45 days) and unresponsive to usual medical and surgical therapy (oxytocine, metergene, antibiotic, and double curettage). The patient was admitted in the Ghaem Hospital, Mashhad University of Medical Sciences in April 2013. She suf-fered from rectal hemorrhage and severe weakness. Because of unsuitable condition (shock), laparotomy was performed and small bowel involvement was observed. Seg-mental resection of small bowel detected metastatic choriocarcinoma of the lesion. We couldn’t rescue our patient due to unresponsive to combination chemotherapy (actino-mycine, methotrexate, cyclophosfamide, vincrystine, etopuside). Conclusion: In abnormal postpartum hemorrhage, we should consider the possibility of choriocarcinoma. Although, it is important to note rare manifestations of metastatic choriocarcinoma of small bowel in massive gastrointestinal hemorrhage.

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Background: Maternal mortality is one of the most important indicators of women health standard in developing countries. This study aimed to determine the prevalence of risk factors and etiology of maternal mortality in a geographic region of Iran. Methods: This descriptive- analytic cross sectional study included all pregnant women who died during pregnancy and six weeks after delivery due to pregnancy related fac-tor. The study was done in Sistan region in the north of Sistan and Baluchestan Prov-ince of Iran from April 2002 to March 2014. The immigrant women were excluded. Data were collected using 3 parts questionnaire. The validity and reliability of ques-tioner were approved by experts in this field. Data were analyzed using the statistical software SPSS version 18, Chi-square test and ANOVA analysis were performed. Results: The total number of deliveries during this time period was 60496. The total number of maternal mortality was 57 patients which means 94.2 out of 100.000 live births. Most of the dead mothers had more than 35 years old (46.9%), gestational age was more than 22 weeks (77.2%), gravidity more than 4 (21.1%), pregnancy interval lower than two years (46.9%) and 75.4% of death was in post-partum. The main cause of mortality was post-partum hemorrhage (19.3%). Conclusion: Based on our findings, some factors including multiparity, pregnancy his-tory more than 4 times, short interval between pregnancies lower than 2 years and ma-ternal age more than 35 years were some risk factors for maternal death. Maternal mortality in the postpartum period was more than pre-delivery period. Bleeding was the main cause of maternal mortality. Therefore monitoring of vital signs in the post-partum period and the proper management of bleeding are very important. It is sug-gested that risk assessment should be done for pregnant women in delivery ward for detecting high risk pregnant women. Suitable management for these women especially for patients with postpartum hemorrhage plays an important role to decrease the ma-ternal mortality.

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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.

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Results: Sublingual misoprostol in combination with oxytocin infusion during cesarean section led to a significant decrease in postoperative blood loss for six hours after the surgery (P<0.001). The decline in the hemoglobin and hematocrit levels and the amount of intraoperative hemorrhage were the same in both groups. Less additional uterotonic agents were needed in the misoprostol group. The frequency of fever and other side effects were similar in the two groups. Conclusion: It seems that adding sublingual misoprostol to oxytocin infusion among high-risk women for postpartum hemorrhage is more effective for reducing blood loss during and after cesarean section.