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A case of unruptured tubal pregnancy diagnosed by gynecography
A CASE OF UNRUPTURED TUBAL PREGNANCY BY GYNECOGRAPHY” IRVING F. (From
STEIN, the
M.D.,
Nichael
CHICAGO,
Reese
DIAGNOSED
ILL.
lirospital)
T
HE inconstancy of the clinical picture of unruptured tubal pregnancy is universally recognized. If there is one reliable and dependable sign of this condition, it is the extreme tenderness found on palpation of the affected tube. When this sign is absent, as in the case In this reported below, the diagnosis is likely to be especially difficult. case, gynecographyl (pneumoroentgenography) proved to be of such positive assistance in diagnosis that it assumed the deciding role. As this method of diagnosis is not commonly employed by the profession in ectopic pregnancy, and in order to call attention to its value in clinical diagnosis, this case report is made.
Fig.
l.-Unruptured
tubal CASE
pregnancy
(gynecography)
.
REPORT
M. W., a 24-year-old woman, nullipara, married 21/, years, was first examined in the office Oct. 2, 1941. The history was that the menses, which had been regular 2%day type, s-day moderate flow since the onset at age II, were one week late m September, appearing on September 17, and then reappearing on September 26, accompanied by sharp left abdominal pain. The patient stated that contraception had been practiced until one month ago, and then intentionally interrupted. She gave a vague history of renal calculus last year. Physical Examination.-The breasts were large, soft, but showed no typical evidence of pregnancy change. The uterus, normal in size, was retroverted and mobile. Both adnexa were free from tenderness and palpable swelling. The cervix was nulliparous, closed, and contained a *Presented
at a meeting
of the Chicago
Gynecological 525
Society,
October
17, 1941.
526
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYSECOLOGT
clear mucous secretion. Rectovaginal-abdominal examination revea1ec.l the same findings. Pulse was 84; color, normal; blood pressure, 130/88; weight, 152 pounds. Urine showed a trace of albumin; no sugar; pH, 5.0; epithelial cells and occasional red blood cells in the sediment. Tentative Diagnos&-Suspected tubal pregnancy. Re-examination was advised in a few days when pregnancy tests were to be carried out. She was warned of possible danger and symptoms which might occur. Four days later, October 6, she had an acute attack of pain in the left- side during the night, and was sent to the Michael Reese Hospital by a neighborhood physician who also thought she had an ectopic pregnancy. Tipon arrival at the hospital at, 3:00 A.M., however, her pain had subsided and the abdomen was neither tender nor rigid. There was slight, pink vaginal discharge. Examination revealed her pulse 92 (varied from 84 to 96), blood pressure 110/70, hemoglobin 70 to 80 per cent,, red blood count 3,740,000, white count 14,000. and the urinalysis negative. Bimanual examination revealed the same findings as in the first instance, complete absence of adnexal tenderness or mass, which made the diagnosis of tubal pregnancy questionable. The differential diagnosis to be made was: (1) tubal pregnancy, (2) intrauterine threatened abortion, (3) ureteritis or calculus, and (4) left corpus luteum cyst. Various diagnostic procedures were considered and a decision was made to obtain a pelvic pneumogram using the transabdominal rout’e (CO, inflation). The film (Fig. 1) accurately revealed the affected tube, showing the changes characteristic of tubal pregnancy. The shadow of both ovaries, ut,erus, and unaffected right tube appeared normal. Laparotomy was performed through a Pfannenstiel incision, and an unruptured tubal pregnancy was removed. The similarity between the shape and size of the involved tube and the image which it produced on the x-ray film was indeed striking. REFERENCE
1. Stein, I. F.: 310
SOUTH
AX. J. MICHIGAN
W.
OBST.
& GYNEV.
43:
400,
1942.
AVENVE
C.
THECA
CELL
TUMOR’
DANFORTH,
M.D.,
EVANSTOK,
ILL.
N RECENT years tumors of the Oraafian follicle have been the subject of much study. While tumors of pure granulosa or theca type are not common, those in which granulosa cells predominate are far more numerous. In a recent report, Curtis stated that 33 theca cell tumors have been reported and added one to that number. In my service, a tumor predominantly composed of theta cells has been seen recently. In January, 1941, a private patient, aged 58 years, entered the hospital for the removal of a large pelvic tumor. Her menopause had occurred six years earlier. At 32 years of age a laparotomy had
I
*Presented
at
& meeting
of
the
Chicago
Gynecological
Society.
October
17.
1941.
STEIN, the
M.D.,
Nichael
CHICAGO,
Reese
DIAGNOSED
ILL.
lirospital)
T
HE inconstancy of the clinical picture of unruptured tubal pregnancy is universally recognized. If there is one reliable and dependable sign of this condition, it is the extreme tenderness found on palpation of the affected tube. When this sign is absent, as in the case In this reported below, the diagnosis is likely to be especially difficult. case, gynecographyl (pneumoroentgenography) proved to be of such positive assistance in diagnosis that it assumed the deciding role. As this method of diagnosis is not commonly employed by the profession in ectopic pregnancy, and in order to call attention to its value in clinical diagnosis, this case report is made.
Fig.
l.-Unruptured
tubal CASE
pregnancy
(gynecography)
.
REPORT
M. W., a 24-year-old woman, nullipara, married 21/, years, was first examined in the office Oct. 2, 1941. The history was that the menses, which had been regular 2%day type, s-day moderate flow since the onset at age II, were one week late m September, appearing on September 17, and then reappearing on September 26, accompanied by sharp left abdominal pain. The patient stated that contraception had been practiced until one month ago, and then intentionally interrupted. She gave a vague history of renal calculus last year. Physical Examination.-The breasts were large, soft, but showed no typical evidence of pregnancy change. The uterus, normal in size, was retroverted and mobile. Both adnexa were free from tenderness and palpable swelling. The cervix was nulliparous, closed, and contained a *Presented
at a meeting
of the Chicago
Gynecological 525
Society,
October
17, 1941.
526
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYSECOLOGT
clear mucous secretion. Rectovaginal-abdominal examination revea1ec.l the same findings. Pulse was 84; color, normal; blood pressure, 130/88; weight, 152 pounds. Urine showed a trace of albumin; no sugar; pH, 5.0; epithelial cells and occasional red blood cells in the sediment. Tentative Diagnos&-Suspected tubal pregnancy. Re-examination was advised in a few days when pregnancy tests were to be carried out. She was warned of possible danger and symptoms which might occur. Four days later, October 6, she had an acute attack of pain in the left- side during the night, and was sent to the Michael Reese Hospital by a neighborhood physician who also thought she had an ectopic pregnancy. Tipon arrival at the hospital at, 3:00 A.M., however, her pain had subsided and the abdomen was neither tender nor rigid. There was slight, pink vaginal discharge. Examination revealed her pulse 92 (varied from 84 to 96), blood pressure 110/70, hemoglobin 70 to 80 per cent,, red blood count 3,740,000, white count 14,000. and the urinalysis negative. Bimanual examination revealed the same findings as in the first instance, complete absence of adnexal tenderness or mass, which made the diagnosis of tubal pregnancy questionable. The differential diagnosis to be made was: (1) tubal pregnancy, (2) intrauterine threatened abortion, (3) ureteritis or calculus, and (4) left corpus luteum cyst. Various diagnostic procedures were considered and a decision was made to obtain a pelvic pneumogram using the transabdominal rout’e (CO, inflation). The film (Fig. 1) accurately revealed the affected tube, showing the changes characteristic of tubal pregnancy. The shadow of both ovaries, ut,erus, and unaffected right tube appeared normal. Laparotomy was performed through a Pfannenstiel incision, and an unruptured tubal pregnancy was removed. The similarity between the shape and size of the involved tube and the image which it produced on the x-ray film was indeed striking. REFERENCE
1. Stein, I. F.: 310
SOUTH
AX. J. MICHIGAN
W.
OBST.
& GYNEV.
43:
400,
1942.
AVENVE
C.
THECA
CELL
TUMOR’
DANFORTH,
M.D.,
EVANSTOK,
ILL.
N RECENT years tumors of the Oraafian follicle have been the subject of much study. While tumors of pure granulosa or theca type are not common, those in which granulosa cells predominate are far more numerous. In a recent report, Curtis stated that 33 theca cell tumors have been reported and added one to that number. In my service, a tumor predominantly composed of theta cells has been seen recently. In January, 1941, a private patient, aged 58 years, entered the hospital for the removal of a large pelvic tumor. Her menopause had occurred six years earlier. At 32 years of age a laparotomy had
I
*Presented
at
& meeting
of
the
Chicago
Gynecological
Society.
October
17.
1941.