- Email: [email protected]
Echinococcus discovered during pregnancy
COMMUNICATIONS IN BRIEF
This section is suitable for reporting cases, results of therapeutic trials, and descriptions of new procedures or instruments. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
istration of sulfur colloid labeled with radioactive technetium confirmed the presence of a spaceoccupying lesion in the left lobe of the liver. The erythrocyte sedimentation rate was 35 mm. per hour. A Casoni test was positive. Further investigation during the postoperative course included normal x-rays of the chest, abdomen, and upper gastrointestinal tract. Liver function tests and serum protein levels were normal. A lung scan (with macroaggregates of human albumin labeled with radioactive technetium) and a brain scan (with intravenous radioactive technetium) did not reveal any further evidence of the disease. At a second laparotomy, the left liver lobe was resected and a cystic mass measuring 11.5 by 6 by 8 em. was removed. The gross and mil;roscopic pictures were similar to those of the pelvic mass.
Echinococcus discovered during pregnancy STEFAN SEMCHYSHYN, B.Sc., M.D. Department of Obstetrics and Gynaecology, Saint Michael's Hospital, Toronto, Ontario, Canada E c H 1 N o c o c c u s is the smallest tapeworm of medical significance. Hippocrates' description of patients with a "liver full of water" illustrates the tendency of the cysts to develop in the liver most commonly, but sometimes they are found in other sites, such as the lung or peritoneal cavity. The following case report of a peritoneal cyst is of interest because of its association with pregnancy.
The natural primary carriers of the echinococcus are dogs and wolves. Transmission to man may be direct or by contaminated foods, particularly meat. The increasing incidence in many countries appears to be related to the degree of development of the cattle industry. 1 In Italy, 50 to 90 per cent of cattle are found to be infected. The incidence of diagnosed echinococcal disease in human subjects varies from 1.6 per ten million people in England to 5,240 per ten million in Argentina. 1 With the use of the Casoni skin test (this is said to be positive in 93 per cent of patients with living cysts 2 ), the infection rate among Canadian Indians is found to vary from 10 to 42 per cent. 3 However, only about 50 operations per year are performed for removal of cysts in this country. Of those patients who had operations, the majority were immigrant Icelanders in whom the cysts were found in the liver. Among the native Canadians, the common site was the lung. In the woman, intra-abdominal disease is found most commonly in the pouch of
The patient, a 26-year-old para 0 hairdresser, had emigrated from Italy 2 years previously. On examination, a fixed, nontender cystic mass, approximately 4 by 6 em. was found behind the uterus, which was of normal size for a 12 week pregnancy. At this time, the pregnancy was terminated by curettage for social reasons. Ten weeks later, she was admitted to this hospital for removal of the cyst, which had increased to 6 by 8 em. At laparotomy, the cyst was found to be 8 by 7 by 6 em., firmly fixed in the cul-de-sac, and covered over by the small and large bowels. A cross section revealed a multiloculated cyst which had glistening walls and was filled with clear fluid. Subsequent histologic examination of the pelvic mass revealed scolices. A thin-walled cystic mass measuring about 5 em. in diameter was felt in the left lobe of the liver. A liver scan with the use of intravenous adminReprint requests: Dr. Stefan Semchyshyn, Department of Obstetrics and Gynecology, Saint Michael's Hospital, 30 Bond St., Toronto 2, Ontario, Canada.
283
284 Communications in brief
Douglas and often presents as a pelvic tumor which obstructs labor. In 1899, Gemmell 4 described a freely mobile mass which could be moved out of the pelvis. After delivery, this was found to be an omental hydatid cyst. In 1902, Franta 5 reported 36 cases associated with complications of labor and delivery Embrey 6 reported 2 patients in 1938. More recent reports are rare. 1 The pelvic mass usually is considered to be secondary to a leak in a liver cyst. Surgical excision is the main therapy, although chemotherapy may be of some value. 8 Prophylaxis by avoidance of contaminated foodstuffs is important. Appreciation is expressed to Dr. C. Luttor for permission to report this case. REFERENCES
J. F., Lopez Adaros, H., and Trejos, A.: Am. J. Trop. Med. Hyg. 20: 224, 1971. Schwartz, S. 1.: Principles of Surgery, New York, 1969, McGraw-Hill Book Company, Inc., p. 1043. Cameron, T. W. M.: Parassitologia 2: 381, 1960. Gemmell, J. E.: Br. Med. J. 2: 1603, 1899. Franta, J.: Ann. Gynecol. Obstet. 57: 165, 1902. Embrey, M. P.: Br. Med. J. 2: 1201, 1938. Guz, A., and Lea, P. A. W.: Br. Med. J. 1: 385, 1956. Baltzly, R., Burrows, R. B., Harfenist, M., et a!.: Nature 206: 408, 1965.
l. Williams,
2. 3. 4. 5. 6. 7. 8.
Pretreatment with laminaria tents before mid-trimester abortion with intra-amniotic prostaglandin F2, PHILLIP G. STUBBLEFIELD, M.D. FREDERICK NAFTOLIN, M.D., PH.D. FREDRIC D. FRIGOLETTO, M.D. KENNETH J. RYAN, M.D. Department of Obstetrics and Gynecology, Harvard Medical School, and the Boston Hospital for Women, Lying·ln Division, Boston, Massachusetts.
T H E u s E oF tents of Laminaria digitata as an adjunct to abortion has recently been reSupported by a grant from the Rockefeller Foundation. Reprint requests: Dr. Frederick Naftolin, Department of Obstetrics and Gynecology, Han•ard Medical School, 45 Shattuck St.., Boston, Massachusetts 02115.
Januaty 15. 1974 Am. ]. Obstet. Gynecol.
discovered in the United States. The use of laminaria tents inserted at the same time as saline infusion is performed has been reported with a definite shortening of the time of ahortion. 1 Wf' have used laminaria tents for pretreatment prior to intra-amniotic injection of prostaglandin in 11 patients, 16 to 20 weeks pregnant. Our method was as follows: Patients were admitted to the hospital in the late afternoon. After exposure with a sterile speculum, the cervix was washed with benzalkonium chloride.* The cervix was grasped with a large Allis clamp, and the endocervical canal was prepared with small sterile swabs dipped in povidone-iodinet solution. A sterile sound was inserted just through the internal os which was then swabbed for a bacterial culture. One to three sterile laminaria tents, 1 to 5 mm. in diametert were coated with lubricating jelly§ and inserted until 5 mm. projected beyond the external cervical os. Two opened 4 by 4 gauze sponges soaked in benzalkonium chloride were draped over the cervix with their edges tucked into the fornices to prevent expulsion of the laminaria. Two more 4 by 4 gau~e sponges were also packed into the vagina to hold the tents in place until they began expanding. The following morning, 14 to 19 hours later, the laminaria tents were removed, the endocervix was recultured, and 40 mg. of prostaglandin F 2 a was then instilled by abdominal amniocentesis as previously described." The mean time from instillation of prostaglandin to abortion was 9.6 ± 6. 7 hours, a dramatic improvement over our results with either intra-ammotiC prostaglandin alone or intraamniotic saline (Fig. I and Table I). None of our 11 patients had any fever or other clinical evidence of infection. The rate of operative removal of the placenta in pretreated patients ( 4/11) was the same as in the non pretreated prostaglandin patients ( 7/20) . The cervical dilatation before intra-amniotic infusion obviated the possibility of lower segment tears caused by lack of cervical dilatation. Although our patients were hospitalized for laminaria insertion, there is no reason why this could not be done as an outpatient procedure
*Zephiran chloridr, Winthrop Labs., Div. of Sterling Drug Inc., New York, New York. tBetadine, Purdue Frederick Co., Yonkers, New York. tPurchased from Milex Products, Chicago, Illinois, or Eshmann-USA. §Sterile Lubricating Jelly, Holland-Rantos Co., Inc., Piscataway, New Jersey.
This section is suitable for reporting cases, results of therapeutic trials, and descriptions of new procedures or instruments. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
istration of sulfur colloid labeled with radioactive technetium confirmed the presence of a spaceoccupying lesion in the left lobe of the liver. The erythrocyte sedimentation rate was 35 mm. per hour. A Casoni test was positive. Further investigation during the postoperative course included normal x-rays of the chest, abdomen, and upper gastrointestinal tract. Liver function tests and serum protein levels were normal. A lung scan (with macroaggregates of human albumin labeled with radioactive technetium) and a brain scan (with intravenous radioactive technetium) did not reveal any further evidence of the disease. At a second laparotomy, the left liver lobe was resected and a cystic mass measuring 11.5 by 6 by 8 em. was removed. The gross and mil;roscopic pictures were similar to those of the pelvic mass.
Echinococcus discovered during pregnancy STEFAN SEMCHYSHYN, B.Sc., M.D. Department of Obstetrics and Gynaecology, Saint Michael's Hospital, Toronto, Ontario, Canada E c H 1 N o c o c c u s is the smallest tapeworm of medical significance. Hippocrates' description of patients with a "liver full of water" illustrates the tendency of the cysts to develop in the liver most commonly, but sometimes they are found in other sites, such as the lung or peritoneal cavity. The following case report of a peritoneal cyst is of interest because of its association with pregnancy.
The natural primary carriers of the echinococcus are dogs and wolves. Transmission to man may be direct or by contaminated foods, particularly meat. The increasing incidence in many countries appears to be related to the degree of development of the cattle industry. 1 In Italy, 50 to 90 per cent of cattle are found to be infected. The incidence of diagnosed echinococcal disease in human subjects varies from 1.6 per ten million people in England to 5,240 per ten million in Argentina. 1 With the use of the Casoni skin test (this is said to be positive in 93 per cent of patients with living cysts 2 ), the infection rate among Canadian Indians is found to vary from 10 to 42 per cent. 3 However, only about 50 operations per year are performed for removal of cysts in this country. Of those patients who had operations, the majority were immigrant Icelanders in whom the cysts were found in the liver. Among the native Canadians, the common site was the lung. In the woman, intra-abdominal disease is found most commonly in the pouch of
The patient, a 26-year-old para 0 hairdresser, had emigrated from Italy 2 years previously. On examination, a fixed, nontender cystic mass, approximately 4 by 6 em. was found behind the uterus, which was of normal size for a 12 week pregnancy. At this time, the pregnancy was terminated by curettage for social reasons. Ten weeks later, she was admitted to this hospital for removal of the cyst, which had increased to 6 by 8 em. At laparotomy, the cyst was found to be 8 by 7 by 6 em., firmly fixed in the cul-de-sac, and covered over by the small and large bowels. A cross section revealed a multiloculated cyst which had glistening walls and was filled with clear fluid. Subsequent histologic examination of the pelvic mass revealed scolices. A thin-walled cystic mass measuring about 5 em. in diameter was felt in the left lobe of the liver. A liver scan with the use of intravenous adminReprint requests: Dr. Stefan Semchyshyn, Department of Obstetrics and Gynecology, Saint Michael's Hospital, 30 Bond St., Toronto 2, Ontario, Canada.
283
284 Communications in brief
Douglas and often presents as a pelvic tumor which obstructs labor. In 1899, Gemmell 4 described a freely mobile mass which could be moved out of the pelvis. After delivery, this was found to be an omental hydatid cyst. In 1902, Franta 5 reported 36 cases associated with complications of labor and delivery Embrey 6 reported 2 patients in 1938. More recent reports are rare. 1 The pelvic mass usually is considered to be secondary to a leak in a liver cyst. Surgical excision is the main therapy, although chemotherapy may be of some value. 8 Prophylaxis by avoidance of contaminated foodstuffs is important. Appreciation is expressed to Dr. C. Luttor for permission to report this case. REFERENCES
J. F., Lopez Adaros, H., and Trejos, A.: Am. J. Trop. Med. Hyg. 20: 224, 1971. Schwartz, S. 1.: Principles of Surgery, New York, 1969, McGraw-Hill Book Company, Inc., p. 1043. Cameron, T. W. M.: Parassitologia 2: 381, 1960. Gemmell, J. E.: Br. Med. J. 2: 1603, 1899. Franta, J.: Ann. Gynecol. Obstet. 57: 165, 1902. Embrey, M. P.: Br. Med. J. 2: 1201, 1938. Guz, A., and Lea, P. A. W.: Br. Med. J. 1: 385, 1956. Baltzly, R., Burrows, R. B., Harfenist, M., et a!.: Nature 206: 408, 1965.
l. Williams,
2. 3. 4. 5. 6. 7. 8.
Pretreatment with laminaria tents before mid-trimester abortion with intra-amniotic prostaglandin F2, PHILLIP G. STUBBLEFIELD, M.D. FREDERICK NAFTOLIN, M.D., PH.D. FREDRIC D. FRIGOLETTO, M.D. KENNETH J. RYAN, M.D. Department of Obstetrics and Gynecology, Harvard Medical School, and the Boston Hospital for Women, Lying·ln Division, Boston, Massachusetts.
T H E u s E oF tents of Laminaria digitata as an adjunct to abortion has recently been reSupported by a grant from the Rockefeller Foundation. Reprint requests: Dr. Frederick Naftolin, Department of Obstetrics and Gynecology, Han•ard Medical School, 45 Shattuck St.., Boston, Massachusetts 02115.
Januaty 15. 1974 Am. ]. Obstet. Gynecol.
discovered in the United States. The use of laminaria tents inserted at the same time as saline infusion is performed has been reported with a definite shortening of the time of ahortion. 1 Wf' have used laminaria tents for pretreatment prior to intra-amniotic injection of prostaglandin in 11 patients, 16 to 20 weeks pregnant. Our method was as follows: Patients were admitted to the hospital in the late afternoon. After exposure with a sterile speculum, the cervix was washed with benzalkonium chloride.* The cervix was grasped with a large Allis clamp, and the endocervical canal was prepared with small sterile swabs dipped in povidone-iodinet solution. A sterile sound was inserted just through the internal os which was then swabbed for a bacterial culture. One to three sterile laminaria tents, 1 to 5 mm. in diametert were coated with lubricating jelly§ and inserted until 5 mm. projected beyond the external cervical os. Two opened 4 by 4 gauze sponges soaked in benzalkonium chloride were draped over the cervix with their edges tucked into the fornices to prevent expulsion of the laminaria. Two more 4 by 4 gau~e sponges were also packed into the vagina to hold the tents in place until they began expanding. The following morning, 14 to 19 hours later, the laminaria tents were removed, the endocervix was recultured, and 40 mg. of prostaglandin F 2 a was then instilled by abdominal amniocentesis as previously described." The mean time from instillation of prostaglandin to abortion was 9.6 ± 6. 7 hours, a dramatic improvement over our results with either intra-ammotiC prostaglandin alone or intraamniotic saline (Fig. I and Table I). None of our 11 patients had any fever or other clinical evidence of infection. The rate of operative removal of the placenta in pretreated patients ( 4/11) was the same as in the non pretreated prostaglandin patients ( 7/20) . The cervical dilatation before intra-amniotic infusion obviated the possibility of lower segment tears caused by lack of cervical dilatation. Although our patients were hospitalized for laminaria insertion, there is no reason why this could not be done as an outpatient procedure
*Zephiran chloridr, Winthrop Labs., Div. of Sterling Drug Inc., New York, New York. tBetadine, Purdue Frederick Co., Yonkers, New York. tPurchased from Milex Products, Chicago, Illinois, or Eshmann-USA. §Sterile Lubricating Jelly, Holland-Rantos Co., Inc., Piscataway, New Jersey.