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BACKGROUND: Primary hyperparathyroidism is the most common cause of hypercalcemia in the general population. It is a rare complication of pregnancy that is difficult for clinicians to recognize, yet it can have important and devastating effects for both mother and baby. CASE: A 27-year-old primigravida at 32+3 weeks' gestation had a serum calcium level in excess of 2.75 mmol/L and evidence of HELLP syndrome. She underwent concurrent parathyroidectomy and Caesarean section. Neither the mother nor the neonate developed hypocalcemia postoperatively. The mother's parathyroid tissue was pathologically atypical, and a left hemithyroidectomy was performed at three months postpartum. CONCLUSION: When hyperparathyroidism is diagnosed in the third trimester, concurrent parathyroidectomy and Caesarean section is a safe and reasonable option for management. This should be performed by a multidisciplinary team with careful monitoring of the calcium levels of both mother and neonate after surgery.

Contexte : L'hyperparathyroïdie primaire constitue la cause la plus courante d'hypercalcémie au sein de la population générale. Bien qu'il s'agisse d'une complication rare de la grossesse qui est difficile à reconnaître pour les cliniciens, elle peut exercer d'importants effets dévastateurs tant chez la mère que chez l'enfant. Cas : Une primigravide de 27 ans à 32+3 semaines de gestation présentait un taux sérique de calcium dépassant 2,75 mmol/l et des symptômes indiquant la présence du syndrome HELLP. Elle a subi, de façon concomitante, une parathyroïdectomie et une césarienne. Ni la mère ni le nouveau-né n'en sont venus à présenter une hypocalcémie postopératoire. L'examen pathologique a révélé que le tissu parathyroïde de la mère était atypique et une hémithyroïdectomie gauche a été menée à trois mois postpartum. Conclusion : Lorsqu'une hyperparathyroïdie est diagnostiquée au cours du troisième trimestre, la tenue concomitante d'une parathyroïdectomie et d'une césarienne constitue une option sûre et raisonnable pour ce qui est de la prise en charge. Ces interventions devraient être menées par une équipe multidisciplinaire et s'accompagner d'une surveillance rigoureuse des taux de calcium de la mère et du nouveau-né après la chirurgie.

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Herein is described the development of an inferior epigastric pseudoaneurysm caused by a trocar injury during laparoscopic surgery. After the accessory trocar was placed in the left lower quadrant, the patient's condition became clinically unstable, requiring blood transfusions postoperatively and transfer to our tertiary care center. On arrival, she continued to have pain, with a palpable tender mass in the left lower quadrant. A computed tomography scan revealed a 5 × 6-cm mass in the anterior rectus sheath, with central hyperattenuation. This was better characterized at ultrasonography. The findings were consistent with an unstable pseudoaneurysm from the left inferior epigastric artery, with surrounding hematoma. Urgent embolization was performed by Interventional Radiology using coils inserted distal, into, and proximal to the pseudoaneurysm. The patient's condition was stable after the procedure, and she returned to the referring hospital for convalescence. Pseudoaneurysm of the inferior epigastric artery from a trocar injury is a rare occurrence. This case is the first report of a pseudoaneurysm forming in the inferior epigastric artery resulting from a trocar injury during gynecologic surgery.

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BACKGROUND: Established noninvasive pharmacologic means of alleviating pain and anxiety in children undergoing intravenous cannulation are time-consuming, and thus impractical for routine use in the emergency department. Vapocoolant sprays provide transient skin anesthesia within seconds of application. We compared the effect of a new vapocoolant spray to placebo on pain due to intravenous cannulation in children. METHODS: In this double-blind randomized controlled trial, which we conducted between June 1 and Sept. 12, 2006, 80 children aged 6-12 years received either vapocoolant spray or placebo before cannulation. Children rated their pain using a 100-mm colour visual analogue scale. Secondary outcomes included success rate on first attempt at cannulation and pain ratings by the children's parents, nurses and child life specialists. RESULTS: We found a modest but significant reduction in pain with the use of vapocoolant spray (mean difference 19 mm, 95% confidence interval [CI] 6-32 mm; p < 0.01). Cannulation on first attempt was more often successful with the use of vapocoolant spray (85.0%) than with placebo (62.5%) (mean difference 22.5%, 95% CI 3.2%-39.9%; p = 0.03). The number needed to treat to prevent 1 cannulation failure was 5 (95% CI 3-32). Parents (p = 0.04), nurses (p = 0.01) and child life specialists (p < 0.01) considered the children's pain to be reduced with the use of vapocoolant spray. INTERPRETATION: The vapocoolant spray in our study quickly and effectively reduced pain due to intravenous cannulation in children and improved the success rate of cannulation. It is an important option to reduce childhood procedural pain in emergency situations, especially when time precludes traditional interventions. (http://ClinicalTrials.gov trial register no. NCT00130650.).

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