Reprod. Med., Volume 6, Issue 1 (March 2025) – 7 articles

Background/Objective: Actinomyces is a genus of anaerobic gram-positive bacteria. It forms part of human body microbiota commonly in the oral cavity and genital tract. During pregnancy, the organism may cause the rare chorioamnionitis, where the maternal genital tract or other sites such as the oral cavity will be the likely source of the pathogen. This condition may increase the risk of foetal morbidity and mortality, and preterm birth. Methods: The placenta of a 33-year-female, primigravida, who presented with preterm labour and eventual delivery of baby at 20 weeks gestation was sent for histopathological examination. Her antenatal and clinical history were reviewed, to identify possible aetiology for her preterm birth. Results: She is noted to have presented with sudden per-vaginal creamy coloured discharge with no associated odour and no irritation. The discharge became blood staining associated with labour pain, this followed by premature spontaneous rupture of membrane and pre-mature labour. Laboratory tests revealed leucocytosis, neutrophilia, monocytosis, high CRP and elevated derived fibrinogen. The patient was delivered of a live male baby weighing 0.35 kg, who died shortly after birth. Placenta microscopic examination revealed patchy severe acute chorioamnionitis and prominent clusters of Gram-positive filamentous bacteria with histopathologic features of Actinomyces spp. The mother before discharged was treated with oral antibiotic. Conclusions: The intrauterine Actinomyces spp. infection is associated with preterm birth and neonatal mortality, early diagnosis during ante-natal could perhaps prevent preterm birth and reduce the associated neonatal mortality. Full article

Background/Objectives: Evans’ syndrome (ES) is a rare autoimmune disorder characterized by the simultaneous or sequential onset of immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA). Given its rarity, available data concerning the clinical course and optimal management in pregnancy are limited. Methods: We present the case of a 32-year-old woman who experienced ES during her first pregnancy. She had been previously diagnosed with childhood-onset SLE at the age of 14 but had been in treatment-free remission since the age of 24. The treatment of both AIHA and ITP included intravenous immunoglobulins, cyclosporine-A, high dosage oral corticosteroids, and, in the second trimester, rituximab. The delivery was planned at 34 + 6 weeks of gestation (GW); no immunological alterations or infectious complications were detected in the newborn. The post-delivery period was uncomplicated, and the mother was discharged with a normal blood count. A narrative review of available ES cases during pregnancy is also presented. Results: A total of 16 patients with ES in pregnancy were reported, including the one we described. None of them developed major bleedings during gestation, while a case of abruptio placentae with delayed postpartum hemorrhage occurred. ITP was difficult to treat in 4/16 women after delivery; 4/16 patients also developed gestational hypertensive disorders. Perinatal outcomes include 13/17 healthy newborns and 4/17 stillbirths (2 of them were twins), of which 1 was due to fetal AIHA. Gestational age at birth was before 37 GW in 8/17. In 15/16 women, ES resolved after delivery. Conclusions: The occurrence of ES during pregnancy has been rarely reported; it constitutes a clinical challenge due to the need for multiple treatments, including conventional immunosuppressants and/or biologic drugs as steroid-sparing agents. After delivery, ES appeared to be less resistant to treatment than it was during pregnancy. Full article

Background and Clinical Significance: Anti-Leucine-rich glioma inactivated-1 (anti-LGI1) encephalitis is a rare, autoimmune disorder often presenting with limbic encephalitis. The reported incidence of anti-LGI1 is 0.83/million/year, with elderly males accounting for the overwhelming majority of cases. While anti-LGI1 encephalitis is a well-known cause of autoimmune encephalitis in men over 50, our literature review found no published cases in pregnant women. The purpose of this study is to describe a rare presentation of this pathology in an unexpected population. Case Presentation: A 21-year-old gravida 2, para 1001 woman at 20 weeks’ gestation presented with worsening seizure-like activity for the past four months, frequent falls, loss of consciousness, and concern for trauma to the abdomen. Her neurologic workup one month prior revealed a 72 h electroencephalography (EEG) with epileptic seizures of the left frontotemporal region, but a normal magnetic resonance image (MRI) of her head. A repeat MRI during this hospitalization showed bilateral limbic and basal ganglia T2 hyperintensities. She was treated with increasing doses of antiepileptic drugs without improvement and was transferred to a neurology intensive care unit, where she was diagnosed with anti-LGI1 encephalitis. She was initially treated with oral corticosteroids with inadequate response, then with intravenous immunoglobulin therapy (IVIG). Her seizure activity persisted throughout her pregnancy, requiring multiple admissions for IVIG, but she eventually delivered a healthy baby and continues to receive long-term care for her new diagnosis. Conclusions: This case illustrates classic findings of anti-LGI1 encephalitis in a non-classic patient population. Knowledge that such a case exists may serve to broaden the differential diagnoses when physicians are presented with a similar pregnant patient and expand the reported patient population in this rare disease. Full article

Background and Clinical Significance: Borderline ovarian tumors (BOTs) are a rare diagnosis, especially in the adolescent population. This can make initial management and surveillance strategies difficult, given the limited guidelines and experience in this young age group. Case Presentation: We present two cases of recurrent serous BOTs diagnosed in adolescent patients. Both patients were initially treated with fertility-sparing surgery and followed with transabdominal pelvic ultrasounds. Secondary surgical debulking of recurrent disease with uterine preservation was successful in both patients with a long-term disease-free status. Conclusions: Although rare, BOTs can occur in adolescent patients and should be on the differential for ovarian masses in this age group. Fertility-sparing surgical techniques, reproductive endocrinology consultation, surveillance strategies, and hormone replacement therapy should all be taken into consideration when treating adolescent patients with BOTs. Full article

Background: Diagnoses for right lower quadrant pain in women must include both gynecologic and non-gynecologic causes. In this differential, ovarian torsion and appendicitis are both serious etiologies that can require swift surgical intervention. Ovarian torsion is the least common of the two, accounting for 2.7% of emergency surgery cases according to a 10-year review, while the lifetime risk of appendectomy for females is 23.1%. As many as 2–3% of patients undergoing surgery for acute appendicitis are instead found to have ovarian torsion. However, there are currently only rare case reports of these two conditions co-presenting in the same patient simultaneously, with little discussion on how to be better prepared before entering the operating room. Objective: The purpose of this study is to describe this rare co-presentation to better inform providers of this potential complication and to improve future patient care outcomes. Method: A case report of a patient seen at Tripler Army Medical Center, Honolulu, Hawaii, was assessed. Conclusions: This case shows the rare possibility of dual acute etiologies of abdominal pain warranting urgent surgical management. This case also highlights the need for a multidisciplinary approach in the pre-procedural evaluation of possible competing etiologies of acute abdominal pain that warrant surgical management. Additionally, this case brings up interesting ethical questions regarding informed consent, autonomy, and the obligation of intraoperatively consulted surgeons to provide definitive and indicated surgical care in the absence of prior discussion of possible pathology. Full article

Background/Objectives: In the postpartum period, approximately 12% of patients seek care in the emergency department (ED), with a higher representation of Black patients. Hypertension is a common reason for ED visits during this period, often leading to dangerously delayed diagnosis and treatment. Objective: This study aims to assess the time to diagnosis and treatment of hypertensive disorders in the postpartum period in the ED, focusing on potential disparities in care, to identify areas for quality improvement. Design: Retrospective cohort study. Setting: A multi-centered large medical institution in the metro Detroit area. Methods: Postpartum patients (day 2 through day 28) presenting to the ED from November 2015 to December 2022. Exposures: none. Main Outcome Measures: Primary analysis assessed the time elapsed between severe-range blood pressure readings (greater than/equal to 160 systolic and/or 110 diastolic) and the administration of antihypertensives. Secondary analyses assessed the presence of essential laboratory workups such as complete blood counts, complete metabolic panels, and urine protein and creatinine. Results: Among the 430 women who presented to the ED during the postpartum period with hypertension, 372 (86.5%) exhibited severe-range blood pressure (greater than/equal to 160 systolic and/or 110 diastolic). Patients presented on average on postpartum day 6. Of the patients with severe hypertension, only 72% received a complete blood count, 66% underwent evaluation of creatinine and liver profile, and 4% had a urine protein and creatinine test ordered. The average time from severe-range blood pressure reading to antihypertensive administration was 189 min for Black patients and 370 min for White patients. There were no statistically significant differences in the time of the first blood pressure reading, laboratory evaluation, or treatment of severe-range blood pressure between racial groups. Conclusions: This study identifies the most significant area for improvement in the timely administration of antihypertensive medication following severe-range blood pressure readings. Additional areas for improvement were observed in ordering essential laboratory tests to assess the severity of preeclampsia. The institution demonstrated delayed yet equitable care for White and Black patients, contrary to the existing literature indicating potential racial disparities. A targeted quality improvement plan has been implemented to improve the identified areas of concern to adhere to the ACOG’s treatment recommendations for hypertensive disorders of pregnancy. The impact on patient care will be reassessed at the 1-year mark. Full article

Background/Objectives: Previous literature has described that non-white pregnant patients are at increased risk of severe morbidity from obstetric hemorrhage (OBH). Here, we investigate whether such disparities are secondary to delay in the administration of postpartum oxytocin for non-white patients compared to white patients. Methods: This is a retrospective cohort study of all deliveries from 2018 to 2019, comparing (1) Hispanic white or non-white race (HW/NWR) pregnant people and (2) non-Hispanic white (NHW) pregnant people. Our primary outcome was the time from delivery to the first dose of postpartum oxytocin, and our secondary outcome was the frequency of other hemorrhage interventions. Results: Out of 3832 patients with self-identified race and ethnicity recorded in their patient record, 644 patients identified as NHW, and 3188 patients identified as HW/NWR. We found no difference in time to first dose of postpartum oxytocin (p = 0.51), and there was also no difference in the frequency of other hemorrhage-related interventions. Conclusions: Our study found no delay in the administration of postpartum oxytocin for non-white patients. Full article