Clinical-Scientific Notes

Acknowledgements
The authors would like to acknowledge the photography
department of the RWH and Dr Jeremy Grummett of the
Royal Melbourne Hospital.

References
1 Webb JC, Gilson G, Gordon L. Late second stage rupture of
the uterus and bladder with vaginal birth after cesarean
section: A case report and review of the literature. J Matern
Fetal Med 2000; 9: 362365.
2 Forsnes EV, Browning JE, Gherman RB. Bladder rupture
associated with uterine rupture. A report of two cases
occurring during vaginal birth after cesarean. J Reprod Med
2000; 45: 240242.
3 Levrant SG, Wingate M. Midtrimester uterine rupture. A case
report. J Reprod Med 1996; 41: 186190.
4 Nassar A, Usta I, Finianos A, Kaspar H. Spontaneous uterine
rupture following intercourse. Acta Obstet Gynecol Scand 2004;
83: 114115.
5 Passini Junior R, Knobel R, Barini R, Marussi E. Placenta
percreta with silent rupture of the uterus. Sao Paulo Med J
1996; 114: 12701273.
6 Gupta A, Chauhan M, Dahiya P, Sangwan K. Meconium
stained urine: An unusual sign of combined uterine and
bladder rupture. Aust N Z J Obstet Gynaecol 2005; 45: 334.

Figure 1 Ruptured bladder and uterus.

other stages of pregnancy. The majority of cases involving

second trimester uterine rupture are related to termination of
pregnancy.3 Spontaneous uterine rupture has been associated
with placental invasion, previous uterine surgery, congenital
abnormalities of the uterus and coitus.4 Where uterine
rupture involved the bladder, only one case was unassociated
with surgical termination of pregnancy.5 Unusual presenting
symptomatology of combined uterine and bladder rupture
include vernix caseosa in maternal urine and meconium-stained
urine.6 This is the second documented case of spontaneous
uterine and bladder rupture in pregnancy.

February
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Notes

Acquired sideroblastic anaemia following progesterone treatment

in pregnancy
Gabriela BENCAIOVA and Christian BREYMANN
Department of Obstetrics, Zurich University Hospital, Zurich, Switzerland

Key words: anaemia, pregnancy, progesterone, sideroblastic.

Introduction

Case report

Sideroblastic anaemias are a heterogeneous group of

hypoproliferative anaemias. One type, secondary acquired
sideroblastic anaemia, is caused by the toxic effect of various
substances on the bone marrow. Previous case reports showed
the relationship between the toxic effect of sex hormone and
secondary sideroblastic anaemia.14

The patient is a 31-year-old caucasian primigravida. She was

well until the age of 30 years, when she became pregnant.
Because of the bleeding at week 8 of gestation and the
suspicion of imminent abortion, she received oral progesterone
200 mg a day. Her haemoglobin prior to therapy was
10.0 g/dL. Three days later, there was no more bleeding.
Fourteen days later, her haemoglobin was 8.7 g/dL and she
was very tired. The progesterone therapy was immediately
stopped. The blood film showed severe anisocytosis and
poikilocytosis. A bone marrow examination showed more
than 15% ring sideroblasts. Karyotypic analysis was normal.
There was no family history of anaemia. Serum ferritin
was raised to 310 g/L (normal 15150). The white blood
count was normal (4.0 109/L) and platelet count slightly

Correspondence: Dr Gabriela Bencaiova, Department of

Obstetrics, Zurich University Hospital, Frauenklinikstr. 10,
CH-8091 Zurich, Switzerland.
Email: gabriela.bencaiova@usz.ch
DOI: 10.1111/j.1479-828X.2009.00952.x
Received 9 April 2008; accepted 11 October 2008.

2009 The Authors

Journal compilation 2009 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 49: 232 238

235

Clinical-Scientific Notes

increased (332 109/L). Thyroid, renal and liver function tests

were normal, and normal immunoglobulin levels, vitamin B12
and acid folic levels were observed. Antinuclear antibody and
rheumatoid factor tests were negative. Hb electrophoresis,
haptoglobin and lactate dehydrogenase were normal. There
was neither hepatosplenomegaly nor skin hyperpigmentation.
There was neither any history of toxic exposure nor of
ethanol abuse. The pyridoxine and folic acid therapy for
three weeks was administered. After this treatment, the
haemoglobin level was unaltered, 8.8 g/dL. Therefore, two
units of blood transfusion were administered four weeks
after progesterone therapy. Her haemoglobin after transfusions
was 10.7 g/dL and the rest of the pregnancy remained stable
at average 10.6 g/dL. Tthe pregnancy was otherwise uneventful.
The patient gave birth spontaneously during the 40th week.
A healthy boy was born with birthweight 3970 g.

Discussion
This is the first report of acquired sideroblastic anaemia
following progesterone therapy during pregnancy. No other
cause for sideroblastic anaemia was found. The progesterone
therapy was immediately stopped and no further relapse of
anaemia during pregnancy was observed.
Previous case reports have shown the relationship between
the toxic effect of oral administered sex hormone usage or
pregnancy alone, and secondary sideroblastic anaemia.14
The mechanism by which progesterone produces sideroblastic
anaemia is unclear; however, progesterone inhibits the growth
of bone marrow progenitors in vitro.5 An increased sensitivity
to progesterone in the erythroid lineage in vivo has been
demonstrated.1 Progesterone has additionally been shown to

influence the intensity of free erythrocyte protoporphyrin

response to inorganic lead.6 Three previous case reports have
indicated that pregnancy alone can induce sideroblastic
anaemia.24 This pregnancy-induced sideroblastic anaemia
is often called idiopathic sideroblastic anaemia. On the
other hand, the hormonal influence of progesterone and
human placental lactogen both modulate erythropoiesis
during pregnancy.
Further studies are necessary to clarify and explain the
pathogenesis of progesterone-induced sideroblastic anaemia.

References
1 Brodsky RA, Hasegawa S, Fibach E, Dunbar CE, Young NS,
Rodgers GP. Acquired sideroblastic anaemia following
progesterone therapy. Br J Haematol 1994; 87: 859862.
2 Barton JR, Shaver DC, Sibai BM. Successive pregnancies
complicated by idiopathic sideroblastic anaemia. Am J Obstet
Gynecol 1992; 166: 576577.
3 Jackson N, Hamizah I. Sideroblastic anaemia recurring during
two pregnancies. Int J Hematol 1996; 5: 8588.
4 Impey L, Greenwood C, Taylor A, Redman C, Wainscoat J.
Recurrent acquired sideroblastic anaemia in a twin pregnancy.
J Matern Fetal Med 2000; 9: 248249.
5 Smith MA, Lucie NP, Ferguson RJ, Mairs RJ, Smith JG.
Progesterone inhibits proliferation of human marrow colony
forming cells (CFU-GM) through increase prostaglandin
production by marrow macrophages. Br J Haematol 1986; 63:
649658.
6 Buchet JP, Roels H, Lauwerys R. Influence of sex hormones
on free erythrocyte protoporphyrins response to lead in rats.
Toxicol 1978; 9: 361369.

Accidental pregnancy exposure to verteporfin: Obstetrical and

neonatal outcomes: A case report
Marta RODRIGUES,1 Dlia MEIRA,2 Sandra BATISTA1 and Maria Marcelina CARRILHO1
1

Department of Obstetrics and Gynecology and 2Department of Ophthalmology, Vila Nova de Gaia/Espinho E.P.E. Hospital Center,
Vila Nova de Gaia, Portugal

Key words: choroidal neovascularisation, chronic central serous chorioretinopathy, fluorescein angiography, photodynamic
therapy, pregnancy, verteporfin.

Introduction
Verteporfin is a photosensitising drug used in photodynamic
therapy (PDT). Photodynamic therapy is a two-stage process
Correspondence: Dr Marta Alexandra Correia Rodrigues,
Avenida Joo Paulo II, 479, 4410-406 Arcozelo, Vila Nova de
Gaia, Portugal. Email: martaacrodrigues@gmail.com
DOI: 10.1111/j.1479-828X.2009.00951.x
Received 25 March 2008; accepted 11 October 2008.

236

involving the use of verteporfin intravenously injected

combined with laser light.
There are no randomised studies in pregnant women.
Preclinical studies showed no teratogenic effects in rabbits
at doses 10 mg/kg/day (40 times higher than the human
dose). Studies in rat fetuses of dams exhibited an increased
incidence of anophthalmia/microphthalmia, when submitted
to intravenous doses 10 mg/kg/day during organogenesis.
The same animals after 25 mg/kg/day intravenous
administration of verteporfin, also had an increased incidence
of wavy ribs.1

2009 The Authors

Journal compilation 2009 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 49: 232 238