Herpes gestationis is an intensely pruritic bullous eruption that may develop in association with pregnancy trophoblastic tumor, hydatidiform mole, and choriocarcinoma 1.

The term herpes is  used because of the frequent presence of grouped or herpetiform lesions in these women 2.  It is a rare disorder which may affect 1 in 1700 to 50000 pregnancies 3. It occurs only   with pregnancy, hydatidiform mole and choriocarcinoma 1. However clinical course may be  modulated by changes in estrogen and progesterone levels. Exacerbations mayoccur with oral  contraceptives or pregnancy and the severity may vary during the menstrual cycle 1.

A 35 year G2 P1 L1 was admitted on 28th July, 2002 in early third trimester with the  complaints of intensely pruritic erythematous papules and urticarial plaques of 4 weeks  duration. They started as itchy red papules and plaques over the abdomen and slowly spread  to involve the limbs, back, palms, and soles over a period of 2 weeks. She noticed tense  blisters on few of those reddish plaques a week back. There was no oral involvement. There  was no history of drug intake prior to the onset. During her last pregnancy she had similar itchy  reddish plaques one week before delivery which subsided a week after delivery. Systemic examination revealed no abormality. Obstetric examination showed 26 weeks pregnancy. On examination there were multiple erythematous papules, urticarial plaques, and  target lesions seen on the abdomen (Figure 1), back, upper and lower limbs including palms and soles. There were tense blisters with clear fluid on few of those plaques on the limbs.

Although spherocytosis is an autosomal dominant trait in a fifth of the cases it appears to be due to new mutations.

A 27 years old primigravida was seen in out patient clinic when she was 16 weeks pregnant. She was a known case of spherocytosis. Because recurrent episodes of hemolytic anemia and jaundice she had multiple blood transfusions and underwent splenectomy at the age of 10 years. Since then she was put on tablet folic acid 5 mg daily and was given 1.2 mega units of injection benzathine penicillin intramuscularly once in 3 weeks for 5 years.

Following splenectomy she suffered from repeated worm infestations and had nearly 24 attacks of malaria over a period of 10 years. During the above period her hemoglobin ranged between 10 and 11 g/dL and the peripheral smear showed mild eosinophilia, moderate hypochromia, platelet clumps and microspherocytosis. None of her family members suffered from similar problems.

On examination she was not anemic and not jaundiced. Her pregnancy was corresponding to 16 weeks of gestation. In view of her previous medical history, besides the usual investigations she was periodically investigated for anemia, malaria and worm infestation. Throughout the antenatal period her hemoglobin ranged between 10.5 and 11 g/dL, PCV was 39% and leukocyte count 9,900/mm3, with differential count P65L29E6. Her peripheral smear showed microcytic hypochromic anemia with few spherocytes. She was given adequate folate supplementation and her pregnancy progressed well. As infection prevention is vital in cases that had splenectomy, she was given anthelmintics at 20 weeks, 28 weeks and 34 weeks and antimalarial prophylaxis with tablet chloroquine 300 mg once weekly from 20 weeks until 38 weeks of gestation.

The presence of a pelvic mass with suspicious clinical features and elevated CA 125 may be suggestive of gynecological malignancy. Large ascites with hydrothorax is usually associated with benign fibroma or thecoma (Meigs syndrome) and completely resolves after surgery. Pseudo-Meigs syndrome refers to the same features associated with other ovarian or gynecological tumors. Struma ovarii may be present with ascites but it is extremely rare for it to present with pseudo-Meigs syndrome and elevated CA 125 levels.

A 52 year old para 4 menopausal woman was admitted on 4th June, 2004 for gradually enlarging abdominal girth since 4-5 months and shortness of breath. On examination she was found to have ascites, a large right pleural effusion with collapsed lung and an irregular right adenexal mass of approximately 10 x 8 cm size. Pelvic ultrasound revealed a mass with solid and cystic areas, normal endometrium, and undetected ovaries. She had an ascitic fluid examination done elsewhere before admission which showed that it was exudative, lymphocytic and free of malignant cells or acid fast bacilli (AFB). CT showed well defined heterogeneous, enhancing, mass of 9 x 7 cm with areas of necrosis in right adenexal region, ascites, right pleural effusion and absence of lymph node enlargement (Figures 1,2,3). Liver function tests, intravenous pyelograms and barium examination, were all within normal limits. The CA 125 level was elevated at 849.510 iu/mL (normal < 35 iu/mL). Pleural fluid drained on many occasions to relieve breathlessness was found negative for AFB and Mature cystic teratomas account for approximately 20% of all ovarian tumors. Struma ovarii is a monodermal variant, which predominantly contains thyroid tissue (greater than 50%). It constitutes about 2.7% of all ovarian teratomas, with an incidence of 0.1-0.3%. Usually seen in 5th and 6th decades of life, it is seldom diagnosed before an exploratory laparotomy for a pelvic mass the most common presenting symptom 1. Less than a third develop ascites and cases of struma ovarii causing pseudo- Meigs syndrome have been rarely reported 2.

Abstract

An infertile couple came to our centre for semen cryopreservation. Husband was having nonseminomatous germ cell tumor of testis for which he was advised unilateral orchidectomy followed by chemotherapy. Being a medical professional he was aware of the impact of chemotherapy on the semen quality and the treatment modalities available for future conception. Four vials of semen were frozen over a period of 15 days prior to chemotherapy. He subsequently underwent full treatment for his malignancy. He visited us again after 2 years when he was declared cured.

The couple underwent first cycle of intrauterine insemination (IUI) following gonadotrophins stimulation using one of the four frozen semen samples. She did not conceive during that cycle. As the number of semen samples was few, it was decided to change the treatment to intra cytoplasmic sperm injection [ICSI]. An IVF–ICSI procedure was initiated on the long protocol with 300 IU of recombinant FSH. A total of 13 eggs were retrieved, ICSI was performed using the second sample of frozen-thawed semen. Out of the total nine good quality embryos, three were transferred and the remaining six were frozen. Patient failed to conceive. A thawed embryo transfer cycle was performed a month later, which also failed. A second IVF–ICSI cycle was carried out 3 months later with 375 IU of r-FSH. Twenty-eight eggs were retrieved; ICSI was performed after thawing the third semen sample. Fifteen good quality embryos were formed; two were transferred and the remaining 13 frozen. She conceived during this cycle. b hCG done on day 15th of embryo transfer was 280 mlU/ml. Pregnancy was supported with progesterone capsules of 200 mg three times a day for up to 14 weeks of pregnancy. She had routine antenatal care and had an uneventful pregnancy till term. She opted for an elective cesarean section and delivered a healthy male child weighing 3.2 kg.