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A severe case of hyperemesis gravidarum
COMMUNICATIONS IN BRIEF
This section is suitable for reporting results of therapeutic trials, descriptions of new procedures or instruments, and case reports which illustrate a principle. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
A severe case of hyperemesis gravidarum ASHWIN ROBERT
CHATWANI, SCHWARTZ,
M.D. M.D.
Department of Obstetrics and Gynecology, Hospital, Philadelphia, Pennsylvania
Temple University
SEVERE H~PEREME~IS GRAVrDARUMleadingtocompromise of renal and liver function is a rare occurrence. We report here of a case of severe hyperemesis, which led to renal failure and possible fatty liver. The condition necessitated interruption of the pregnancy. S. G., a 20-year-old black woman, was admitted to Temple University Hospital on February 4, 1982, with a history of 10 weeks of amenorrhea and vomiting for 1 month. She also complained of weakness and dizziness. There was no significant past medical or drug history. On physical examination, the blood pressure was 70/40 mm Hg, the pulse rate was 132 bpm, and the skin was dry and warm. The sclera was noted to be icteric. At pelvic examination the uterus was the size of a IO-week gestation.
Laboratory tests showed a hemoglobin level of 14.3 gm/lOO ml and a hematocrit of 41.5%. The serum electrolyte levels were reported as: sodium, 133 mEq/L; potassum, 2.6 mEq/L; chloride, 73 mEq/L; blood urea nitrogen, 120 mg/lOO ml; and serum creatinine, 6.4 mg/lOO ml. Urinalysis revealed proteinuria (2+) but no ketones. Arterial blood gas values were Pco,, 42; bicarbonate, 34; and pH, 7.53. Other abnormal laboratory tests were as follows: uric acid, 26 mg/lOO ml; serum bilirubin, 5.5 mgi100 ml; lactic dehydrogenase, 272 IUIL; alkaline phosphatase, 113 IU/L; and antistreptolysin 0 titer, 222 IUIL. The urinary electrolyte levels were consistent with Reprint requests: Ashwin Chatwani, M.D., Temple University Hospital, Department of Obstetrics and Gynecology, 3401 N. Broad St., Philadelphia, Pennsylvania 19140. 964
dehydration. The real-time ultrasound scan demonstrated a normal intrauterine pregnancy. The patient received nothing by mouth and was given an intravenous infusion of dextrose and saline solution with potassium and a multivitamin supplement. On this regimen the patient showed marked improvement so that by the fourth day of admission the serum electrolyte levels returned to normal with a blood urea nitrogen of 11 mgi 100 ml and a serum creatinine level of 0.8 mg/lOO ml. All other abnormal functions returned to normal with the exception of a bilirubin level of 2.2 mg/lOO ml. Oral feeding was attempted but not tolerated by the patient. Elective abortion was performed on February 9, 1982, by dilatation and evacuation. The nausea and vomiting ceased 2 days following the abortion.
Vomiting is one of the most common of all the tribulations of the first trimester of pregnancy. The number of admissions for hyperemesis has declined over the past few years and has become a very rare indication for termination of a pregnancy. Prolonged vomiting leads to dehydration and the loss of gastric contents, resulting in metabolic alkalosis and hypokalemia. Continued vomiting eventually leads to brain stem lesions resembling Wernicke’s encephalopathy. These lesions are probably due to vitamin B, deficiency.’ Volume depletion leads to renal failure with a subsequent rise in the blood urea nitrogen level. During this period of dehydration, renal conservation of sodium takes precedence over other homeostatic mechanisms.’ Since a large fraction of plasma sodium is paired with bicarbonate in alkalosis, complete reabsorption of filtered sodium requires reabsorption of bicarbonate as well. Thus alkalosis is sustained until the volume depletion is corrected. Renal failure secondary to dehydration can be differentiated from an intrinsic renal cause by measurement of the sodium content in the urine. A urinary sodium content of less than 10 0002-9378/82/160964+02$00.20/0
@ 1982
The
C. V. Mosby
Co.
Volume Number
143 8
Communications
mEq/L favors a diagnosis of dehydration. Absence of ketonuria in our patient could be explained by the presence of metabolic alkalosis. Deposition of fat in the liver can occur from protein and energy malnutrition leading to abnormal liver function tests. Correction of alkalosis requires saline infusion to enhance bicarbonate excretion. A potassium supplement is required to correct hypokalemia. Acidifying agents are very rarely required in the correction of a gastric alkalosis. Physicians are often reluctant to terminate a pregnancy because of hyperemesis, but abortion was deemed necessary in this patient.
normal. On several occasions during the next 4 years, a left cystic mass was palpated but would disappear each time following a sudden gush of brown vaginal discharge. During the latter 2 years, the patient had metrorrhagia between normally spaced periods. At age 22, the patient was admitted to our hospital. On
examination
with a speculum, a small cervix situated at the 9
o’clock position was seen. To the left of the cervix the vaginal dome bulged into the vaginal cavity. The vagina felt cystic on
palpation,
and there was a centrally located pinpoint
Uterus communicans septus, cervix duplex, and vagina septa unilateralis atretica: A previously unreported genital malformation MICHAEL E. TOAFF, ISA VELEZ, M.D.
of py-
M.D.,
M.Sc.
COMMUNICATING UTERI share a basic feature-two distinct uterocervical cavities communicating only at the isthmic level. To date, five distinct types of communicating uteri have been described’ (Types 1,2, Za, 3, and 4 in Fig. 1). We now present a previously unreported genital malformation-uterus communicans septus, cervix duplex, and vagina septa unilateralis atretica with pinpoint vaginovaginal fistula (Type 3a in Fig. 1).
N. K., a 22-year-old black woman, was admitted for evaluation of severe left-sided dysmenorrhea and intermenstrual bleeding. Following menarche at age 10 the patient had regular periods (30-day cycle with 5 days of bleeding) with increasingly severe left lower-quadrant dysmenorrhea. At age 18, after 3 years of Lo-Ovral administration and 3 months of secondary amenorrhea, she presented with heavy bleeding and left lower-abdominal pain. The uterus was found to be by a cystic
mass. At curettage
no products
Reprint requests: Michael E. Toaff, M.D., Department Obstetrics and Gynecology, Pennsylvania 19 102.
230 N. Broad
@ 1982
The
St., Philadelphia,
C. V. Mosby
Co
salpingography contrast medium that was introduced into the cervical canal spilled out promptly through the orifice at the vaginal dome. Repeated injection following clamping of this orifice (Fig. 2), revealed a septate uterus with two separate cervices. An isthmic communication between the two uterocervical cavities was demonstrated. The right cervix was observed to open into a patent right-sided vagina. The left cervix opened into an atretic left hemivagina which had an inferior orifice, i.e., a vaginovaginal fistula. On the lateral aspect of the left cervix, at the isthmic level, a small diverticulum was noted. Bilateral tubal patency also was demonstrated. After the next menstrual period, resection of the inferoresulting in a single vaginal cavity. This exposed the left cervix, which ended 1.5 cm higher than the right cervix. Since the operation, the patient has had regular menstrual periods without dysmenorrhea or intermenstrual spotting.
and Gynecology, lkksion of Reproductive Endocrinology and Infertility, The Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania
OOOZ-9378/82/160965+03$00.30/0
orifice.
a large amount Intravenous
median aspect of the left atretic hemivagina was performed,
B@artment uf Obst&cs
to the right
of this orifice, was discharged.
elography revealed the absence of a left kidney. At hystero-
Donald, I.: Practical Obstetric Problems, ed. 5, London, 1974, Lloyd-Luke (Medical Books) Ltd., p. 249. 2. Levinsky, N. G.: Acidosis and alkalosis, in Isselbacher, K. J., Adams, R. D., Braunwald, E., Petersdorf, R. G., and Wilson, J. D., editors: Harrison’s Principles of Internal Medicine, ed. 9, New York, 1980, McGraw-Hill Book Co., Inc., p. 448. 1.
deviated
965
of conception were recovered. Aspiration of the cystic mass through a vaginal approach yielded dark blood containing small clots. At laparoscopy, the uterus demonstrated a normal external configuration, and the ovaries and tubes appeared
Following surgical dilatation sanguineous, purulent fluid REFERENCES
in brief
of
This case of uterus communicans septus, cervix duplex, and vagina septa unilateralis atretica is, to the best of our knowledge, unique in the literature. Embryologically, this malformation could be predicted. Musset and associate? defined a three-phase process of the median fusion of the two paramesonephric ducts into a unified uterovaginal canal. The first stage (tenth week of gestation) includes median fusion of the two ducts from the level of the isthmic region to the urogenital sinus. The second stage, completed by the thirteenth week, is characterized by cell proliferation, which fills in the triangular space between the two uterine cornua, thus forming the external convexity of the uterine fundus. Simultaneously the cervical and upper vaginal internal median septum is resorbed starting at the isthmus and continuing caudally, thus unifying the cervical canal and upper vagina. The third stage continues through the seventeenth week. The uterine septum is resorbed starting at the isthmic region and heading cephalad toward the fundus. The genital malformation reported here was the result of a selective teratogenic effect that was active during these three stages. All reported cases of communicating uteri with vagina septa unilateralis atretica are associated with ipsilateral renal agenesis.’ The development of the paramesonephric duct is completely dependent upon the
This section is suitable for reporting results of therapeutic trials, descriptions of new procedures or instruments, and case reports which illustrate a principle. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
A severe case of hyperemesis gravidarum ASHWIN ROBERT
CHATWANI, SCHWARTZ,
M.D. M.D.
Department of Obstetrics and Gynecology, Hospital, Philadelphia, Pennsylvania
Temple University
SEVERE H~PEREME~IS GRAVrDARUMleadingtocompromise of renal and liver function is a rare occurrence. We report here of a case of severe hyperemesis, which led to renal failure and possible fatty liver. The condition necessitated interruption of the pregnancy. S. G., a 20-year-old black woman, was admitted to Temple University Hospital on February 4, 1982, with a history of 10 weeks of amenorrhea and vomiting for 1 month. She also complained of weakness and dizziness. There was no significant past medical or drug history. On physical examination, the blood pressure was 70/40 mm Hg, the pulse rate was 132 bpm, and the skin was dry and warm. The sclera was noted to be icteric. At pelvic examination the uterus was the size of a IO-week gestation.
Laboratory tests showed a hemoglobin level of 14.3 gm/lOO ml and a hematocrit of 41.5%. The serum electrolyte levels were reported as: sodium, 133 mEq/L; potassum, 2.6 mEq/L; chloride, 73 mEq/L; blood urea nitrogen, 120 mg/lOO ml; and serum creatinine, 6.4 mg/lOO ml. Urinalysis revealed proteinuria (2+) but no ketones. Arterial blood gas values were Pco,, 42; bicarbonate, 34; and pH, 7.53. Other abnormal laboratory tests were as follows: uric acid, 26 mg/lOO ml; serum bilirubin, 5.5 mgi100 ml; lactic dehydrogenase, 272 IUIL; alkaline phosphatase, 113 IU/L; and antistreptolysin 0 titer, 222 IUIL. The urinary electrolyte levels were consistent with Reprint requests: Ashwin Chatwani, M.D., Temple University Hospital, Department of Obstetrics and Gynecology, 3401 N. Broad St., Philadelphia, Pennsylvania 19140. 964
dehydration. The real-time ultrasound scan demonstrated a normal intrauterine pregnancy. The patient received nothing by mouth and was given an intravenous infusion of dextrose and saline solution with potassium and a multivitamin supplement. On this regimen the patient showed marked improvement so that by the fourth day of admission the serum electrolyte levels returned to normal with a blood urea nitrogen of 11 mgi 100 ml and a serum creatinine level of 0.8 mg/lOO ml. All other abnormal functions returned to normal with the exception of a bilirubin level of 2.2 mg/lOO ml. Oral feeding was attempted but not tolerated by the patient. Elective abortion was performed on February 9, 1982, by dilatation and evacuation. The nausea and vomiting ceased 2 days following the abortion.
Vomiting is one of the most common of all the tribulations of the first trimester of pregnancy. The number of admissions for hyperemesis has declined over the past few years and has become a very rare indication for termination of a pregnancy. Prolonged vomiting leads to dehydration and the loss of gastric contents, resulting in metabolic alkalosis and hypokalemia. Continued vomiting eventually leads to brain stem lesions resembling Wernicke’s encephalopathy. These lesions are probably due to vitamin B, deficiency.’ Volume depletion leads to renal failure with a subsequent rise in the blood urea nitrogen level. During this period of dehydration, renal conservation of sodium takes precedence over other homeostatic mechanisms.’ Since a large fraction of plasma sodium is paired with bicarbonate in alkalosis, complete reabsorption of filtered sodium requires reabsorption of bicarbonate as well. Thus alkalosis is sustained until the volume depletion is corrected. Renal failure secondary to dehydration can be differentiated from an intrinsic renal cause by measurement of the sodium content in the urine. A urinary sodium content of less than 10 0002-9378/82/160964+02$00.20/0
@ 1982
The
C. V. Mosby
Co.
Volume Number
143 8
Communications
mEq/L favors a diagnosis of dehydration. Absence of ketonuria in our patient could be explained by the presence of metabolic alkalosis. Deposition of fat in the liver can occur from protein and energy malnutrition leading to abnormal liver function tests. Correction of alkalosis requires saline infusion to enhance bicarbonate excretion. A potassium supplement is required to correct hypokalemia. Acidifying agents are very rarely required in the correction of a gastric alkalosis. Physicians are often reluctant to terminate a pregnancy because of hyperemesis, but abortion was deemed necessary in this patient.
normal. On several occasions during the next 4 years, a left cystic mass was palpated but would disappear each time following a sudden gush of brown vaginal discharge. During the latter 2 years, the patient had metrorrhagia between normally spaced periods. At age 22, the patient was admitted to our hospital. On
examination
with a speculum, a small cervix situated at the 9
o’clock position was seen. To the left of the cervix the vaginal dome bulged into the vaginal cavity. The vagina felt cystic on
palpation,
and there was a centrally located pinpoint
Uterus communicans septus, cervix duplex, and vagina septa unilateralis atretica: A previously unreported genital malformation MICHAEL E. TOAFF, ISA VELEZ, M.D.
of py-
M.D.,
M.Sc.
COMMUNICATING UTERI share a basic feature-two distinct uterocervical cavities communicating only at the isthmic level. To date, five distinct types of communicating uteri have been described’ (Types 1,2, Za, 3, and 4 in Fig. 1). We now present a previously unreported genital malformation-uterus communicans septus, cervix duplex, and vagina septa unilateralis atretica with pinpoint vaginovaginal fistula (Type 3a in Fig. 1).
N. K., a 22-year-old black woman, was admitted for evaluation of severe left-sided dysmenorrhea and intermenstrual bleeding. Following menarche at age 10 the patient had regular periods (30-day cycle with 5 days of bleeding) with increasingly severe left lower-quadrant dysmenorrhea. At age 18, after 3 years of Lo-Ovral administration and 3 months of secondary amenorrhea, she presented with heavy bleeding and left lower-abdominal pain. The uterus was found to be by a cystic
mass. At curettage
no products
Reprint requests: Michael E. Toaff, M.D., Department Obstetrics and Gynecology, Pennsylvania 19 102.
230 N. Broad
@ 1982
The
St., Philadelphia,
C. V. Mosby
Co
salpingography contrast medium that was introduced into the cervical canal spilled out promptly through the orifice at the vaginal dome. Repeated injection following clamping of this orifice (Fig. 2), revealed a septate uterus with two separate cervices. An isthmic communication between the two uterocervical cavities was demonstrated. The right cervix was observed to open into a patent right-sided vagina. The left cervix opened into an atretic left hemivagina which had an inferior orifice, i.e., a vaginovaginal fistula. On the lateral aspect of the left cervix, at the isthmic level, a small diverticulum was noted. Bilateral tubal patency also was demonstrated. After the next menstrual period, resection of the inferoresulting in a single vaginal cavity. This exposed the left cervix, which ended 1.5 cm higher than the right cervix. Since the operation, the patient has had regular menstrual periods without dysmenorrhea or intermenstrual spotting.
and Gynecology, lkksion of Reproductive Endocrinology and Infertility, The Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania
OOOZ-9378/82/160965+03$00.30/0
orifice.
a large amount Intravenous
median aspect of the left atretic hemivagina was performed,
B@artment uf Obst&cs
to the right
of this orifice, was discharged.
elography revealed the absence of a left kidney. At hystero-
Donald, I.: Practical Obstetric Problems, ed. 5, London, 1974, Lloyd-Luke (Medical Books) Ltd., p. 249. 2. Levinsky, N. G.: Acidosis and alkalosis, in Isselbacher, K. J., Adams, R. D., Braunwald, E., Petersdorf, R. G., and Wilson, J. D., editors: Harrison’s Principles of Internal Medicine, ed. 9, New York, 1980, McGraw-Hill Book Co., Inc., p. 448. 1.
deviated
965
of conception were recovered. Aspiration of the cystic mass through a vaginal approach yielded dark blood containing small clots. At laparoscopy, the uterus demonstrated a normal external configuration, and the ovaries and tubes appeared
Following surgical dilatation sanguineous, purulent fluid REFERENCES
in brief
of
This case of uterus communicans septus, cervix duplex, and vagina septa unilateralis atretica is, to the best of our knowledge, unique in the literature. Embryologically, this malformation could be predicted. Musset and associate? defined a three-phase process of the median fusion of the two paramesonephric ducts into a unified uterovaginal canal. The first stage (tenth week of gestation) includes median fusion of the two ducts from the level of the isthmic region to the urogenital sinus. The second stage, completed by the thirteenth week, is characterized by cell proliferation, which fills in the triangular space between the two uterine cornua, thus forming the external convexity of the uterine fundus. Simultaneously the cervical and upper vaginal internal median septum is resorbed starting at the isthmus and continuing caudally, thus unifying the cervical canal and upper vagina. The third stage continues through the seventeenth week. The uterine septum is resorbed starting at the isthmic region and heading cephalad toward the fundus. The genital malformation reported here was the result of a selective teratogenic effect that was active during these three stages. All reported cases of communicating uteri with vagina septa unilateralis atretica are associated with ipsilateral renal agenesis.’ The development of the paramesonephric duct is completely dependent upon the