- Email: [email protected]
Chorionepithelioma following full-term pregnancy
530
AMERICAN
JOURNAL
OF
ORS’I’ETRIC’R
AND
(;YNEC’OI,O(:Y
anterior part of the germ disk was affectell in such a case of :~r~enc:el~halus, comprising the cells that form t,he oral em1 of the merlulhtry fohls ant1 alwring the l~rimordin of the eyes. Such a view of localized tlrvclopmentel ~lefccts woultl s(‘em to apply in t,his case, as otherwise explanat,ion of :menceph:~lus in oue of itlent,ic:xl twins, the other being structurally normal is #difficult to lnovi~lc. It would seeill t,hat a disparity in the vitality of certain structures in one twin couhl occur locally, resulting in anen cephaly, whereas the other twin might not 1~ so affectell, :mtl would go on to Ilorm:ll development. Acknowledgment is made to Dr. R. Gordon for permission to present this case.
(1) DeLee, J. B. : Principles and :Prac+ice of Obstetrics, ed. -l, Philadelphia, 1925, W. B. Saunders Co. (2) DBderZritt, A.: Handbuch ,der Geburtshilfe, Munich, 1915, J. F. Rergmann. (3) Diet&h, S. : Zentralbl. f. Gynak. 38: 587, 1914. (4) Q~uigley, .T. IC.: A&r. J. OBST. & GYNEC. 29: 354, 1935. (,5) Streetw, Q. T..: Contrib. Embryol.
22: 1, 1930. 185
194
XOILTH SOUTH
WABASH MICHIGAN
AVENUE AVESVE
CHORIONEPITHELIOMA
FULL-TERIM
FOLLOWING
PREGNBVCP" / A CASE REPORT CLIFFORD
(From
the
Department
B. of
LULL,
M.D., PHILADELPHIA,
ObstPtrica
ami.
Gynecology,
PA.
PemsyEvaaia
aospitul)
HORIONEPITHELIONA is associated in most minds with hydatidiform mole, and although the literature shows that a certain percentage does occur after fullterm gestation, nevertheless, inquiry among various members of this society elicited the information that very few had seen &orionepithelioma following normal pregnancy. Inquiry also among the larger clinics in the country, has failed to reveal a very frequent incidence. It was therefore thought advisable to report this case to call the attention to the fart that bleetling following pregmaocy should be looked upon with suspicion. A search of the records of the Philatlelphia Lying-In Hospital shows no case of chorionepithelioma following a full-term pregnancy. All cases of chorionepithelioma recorded followed abortions or hydat,idiform moles. Mrs. M. D., aged twenty-nine, first consulted me when she was approximately three months pregnant. She wds a nulliparous patient who had had influenza in 1918, tonsillectomy in 1926, and an appendectomy in 19% There were no other serious illnesses or operations. Her periods haul been established at the age of fourteen; had always been regular ; normal in amount and duration. Her last period was Dec. 26, 1933, and her expected date of confinement, Oct. 2, 1934. This patient, was seen with regularity during the rest of her pregnancy, and at no time had any disturbing symptoms more than the usual discomfort associated with pregnancy. Her blood pressure, urine, and other findings remained essentially normal. She was admitted to the Lying-In Hospital private service on Oct. 5, 1934. Her pains began at 5 P.M. and at the time of admission, were approximately five-minute intervals, lasting from twenty to thirty seconds. Fetal heart sounds were heard in the right lower quadrant and were of good quality. The blood pressure was 116/50.
C
*Presented
at
a meeting
of the
Obstetrical
Society
of Philadelphia.
May
2. 193.5.
LULL
:
CHORIONEPITHELIOMA
731
Labor progressed normally and at 9 P.M. she was given vi gr. nembutal and I/150 gr. of scopolamine. The scopolamine was repeated at 1 A.M. Analgesia was good, and at 4:30 A.M., Oct. 6, 1934, the head was presenting at the vulva in R.O.A. position. Under light gas anesthesia, a median episiotomy was done and the head was lifted off the perineum. Duration of gas anesthesia was twenty minutes. The third stage was uneventful, the placenta being delivered sixteen minutes after the baby. The usual ernutin and infundin were given. The child was normal and was sent to the nursery in good condition. The patient’s puerperal period was uneventful. At no time during her confinement to the hospital, which lasted eleven days, was there any elevation of temperature or pulse. The perineum healed immediately and the lochial Both mother and child were discharged in discharge was normal on all occasions. good condition on Oct. 17, 1934. The patient was told to report for follow-up examination in four weeks, and her postpuerperal care was outlined before discharge. The subsequent convalescence was normal until Nov. 7, when the patient began to bleed rather freely. She was put to bed, oxytoxic drugs were administered together with sedatives, ancl in two or three days the bleeding stopped. No pelvic examination was made at that time. The patient again resumed her household duties which were limited to caring for the chihl and very minor household details. On the thirteenth of November a sudden hemorrhage occurred, which was severe. She was immediately hospitalized, and ut the time of admission she was in very slight shock. Intravenous injection of glucose together with stimulation was ordered, and the vagina packed temporarily. Six hours later, when the pulse and temperature were normal, she was taken to the operating room and under light gas anesthesia the vaginal packing was removed. The cavity of the uterus was explored with a blunt placental forceps and a few small shreds of decidual tissue removed. Examination under anesthesia showed involution of the uterus to be normal, and no adnexal masses. The uterus was packed, together with the vagina, and the patient returned to her room in good condition. The bloo,d couut the following day showed 64 per cent hemoglobin and 3,000,OOO red cells. The packing was remove11 at the end of thirty six hours. There was no further blreling and on November 22, she was discharged in good condition. While in the hospital her secondary anemia was actively treated. She remainetl in bed from the time of her discharge and was not seen until November 39, one week later. At that time her pulse was running between 90 and 100, and her temperature was normal. But during the entire week at home there had been a slight bright red bloody discharge. As this seemed to be rather unusual, she was again admitted to the hospital, and examined umler nitrous oxide anesthesia (this patient was very difficult to examine without an anesthetic). During the course of the examinat,ion there was a spurt of bright red blood from the uterus, SO that the uterus was again packed to c.ontrol the bleeding. The examination revealetl no pathology that was palpable in the pelvis and the uterus was well involuted. Chorionepithelioma was suspected and a Friedman test taken at this time was shown to be positive in dilutions of 1 to 20. The quite typica elevation of temperature occurred the following day and immediate operation was postponed while the patient was given transfusions and other supportive treatment. There was no further hemorrhage when the packing was removed. Five days later, in spite of an elevation of temperature and pulse, under light nitrous oxide and ether anesthesia, the abdomen was opened. The uterus was small Over the right born there was a slight adhesion between the omeutum and firm. and the peritoneal covering of the uterus. Upon lifting the omentum up, a small area about one-fourth inch in diameter w’as found with a bluish discoloration, and the peritoneal covering of the uterus almost perforated. Panhysterectomy was done as rapidly as possible and the patient left the operating room in good condition. Post-
732
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGT
operative convalescence until December 23, was more or loss uneventful. The temperature receded and the pulse came domu to about DO. Thr mounll he&d by primary union, and there was no unusual ahdon~inal symptoms. On December 30, sixt,een days :lftc:, Ilpcration, the telnp!lxturc! was 1ror1d and the pulse 96. On December 31 the patittnt hrgnn to cough and had definite pulmonary signs. X-ray of the chest on Jan. ::, 19:X, 11y Dr. I’aul Bishop, showed a greaat &~a1 of mottled infiltration throughout lrtrth lungs, but more extcsnsive on the right side and especially marker1 at the right h:rsc). Flis opinion WIR that this was a mctastatic lesion. Reexamination tm J:mu:~ry S sl io\i.t’~l in (listiuc:t incrcast, in amount of lung infiltration. Dr. Hishop’s opinion was tlmt the major portion 01’ the pulmonary lesions was mc+astatic in origin. Pntic,nl ‘s condition l)ec:rnl~~ n~nduallv y worse and by January 11, hat1 tlefinitt, signs of mc~tastasis to the t;r:iin. Death occurred on Jan. 13, 1935. A2rit~~psy wis not per~nittwl. Pathologic examination by Dr. .John l<:au~r showell the uterus to be normal esceld in the region just antcsrior to t 11~1 I igIlt 11or11 \vhc~ till> ~rfa~e was of a (lark reddish blue color and the tis~nc ~lt+litc~ly fatty. I1 en’ :tlso there were trvo hemispherical norlules projecting xl~rvr~ tIlti> .;urfacr of the oqun. One of these nodules, the smaller, was s mn~. in Ircight an11 mc~snr~~l 12 mm. in Iliameter. The top was very soft ant1 llrown as thoriqli necrotic. ThcBre was also :I firm pinkish nodule 4 mm. in height and tli:mit:tc:r 1Irujrc’t in,g frown thr upper surface of the right tube just proximal to its fimbristc~l cn~l. Tllc mucosa of the Vrrvix am1 of tlicl lowrl third of the uterus was not n~:rl in apprar~~nc~. 11 ic.rosalrpic c*Yanrination showed a typical chorioncpitheliomu. 1731
PINE
STRKET
SPONTANEOUS
EVOL~‘TTOS 01‘ PRP?tFYTATTOK* ,L i*
A TRAIYSVERSE
T
RANSVERSE presentations arcs of tr~:asional ot’rurrence, the statistics showing that in about one case in 300, the shoul~ler presents. Transverse presentations which correct themselves spontaneously arc of cxct~e~linglp rar(s oc(-urrenc,l, this happening about once in 3,000 caws. The ease to be presented is of partirular int,erest in that the baby weighed 3,262 gm., t,his weight being exceeded in the eases in the literaturcx,, by that of Rusch 3,500 gm., and that of Herrgott X,300 gm. MorcoYcr, thrl cLntirt* mrchanism was completed in forty minutes.
Mrs. D., forty-two years old, Norwegian Hospital at 3 :00 AN., with the exception of the last, had The one abnormality was afebrile. of the membranes and subsequent The patient ‘s antrcrtl~~nt history case. Last menstrual perioll Kov.
a whittx female, para viii. was allmitt,ad to the Sept. S, 1923, in labor. Her previous pregnancies, all terminated spontaneously am1 each puerperium was a placenta previx latc’ralia, treated by rupture syontanaoun deliver)-. was essfmt,ially negative axul haul no bcariug on the ~‘:tl~ulntt~rl t (‘rL11, .1ug. 24, 1933. I$, 1932.
She had had no prenatal care? but Nixon tIlta onset of Iahl,r, at !I : (10 r.~r., local doctor who examined her vaginally, ruptured the mem!~ranes artificially, with obvious excitement,. told her that something was wrong. and suggested *Presented
at a meeting
of
the
Brooklyn
Gynecological
Society.
April
called her and then hospital5. 199.5.
AMERICAN
JOURNAL
OF
ORS’I’ETRIC’R
AND
(;YNEC’OI,O(:Y
anterior part of the germ disk was affectell in such a case of :~r~enc:el~halus, comprising the cells that form t,he oral em1 of the merlulhtry fohls ant1 alwring the l~rimordin of the eyes. Such a view of localized tlrvclopmentel ~lefccts woultl s(‘em to apply in t,his case, as otherwise explanat,ion of :menceph:~lus in oue of itlent,ic:xl twins, the other being structurally normal is #difficult to lnovi~lc. It would seeill t,hat a disparity in the vitality of certain structures in one twin couhl occur locally, resulting in anen cephaly, whereas the other twin might not 1~ so affectell, :mtl would go on to Ilorm:ll development. Acknowledgment is made to Dr. R. Gordon for permission to present this case.
(1) DeLee, J. B. : Principles and :Prac+ice of Obstetrics, ed. -l, Philadelphia, 1925, W. B. Saunders Co. (2) DBderZritt, A.: Handbuch ,der Geburtshilfe, Munich, 1915, J. F. Rergmann. (3) Diet&h, S. : Zentralbl. f. Gynak. 38: 587, 1914. (4) Q~uigley, .T. IC.: A&r. J. OBST. & GYNEC. 29: 354, 1935. (,5) Streetw, Q. T..: Contrib. Embryol.
22: 1, 1930. 185
194
XOILTH SOUTH
WABASH MICHIGAN
AVENUE AVESVE
CHORIONEPITHELIOMA
FULL-TERIM
FOLLOWING
PREGNBVCP" / A CASE REPORT CLIFFORD
(From
the
Department
B. of
LULL,
M.D., PHILADELPHIA,
ObstPtrica
ami.
Gynecology,
PA.
PemsyEvaaia
aospitul)
HORIONEPITHELIONA is associated in most minds with hydatidiform mole, and although the literature shows that a certain percentage does occur after fullterm gestation, nevertheless, inquiry among various members of this society elicited the information that very few had seen &orionepithelioma following normal pregnancy. Inquiry also among the larger clinics in the country, has failed to reveal a very frequent incidence. It was therefore thought advisable to report this case to call the attention to the fart that bleetling following pregmaocy should be looked upon with suspicion. A search of the records of the Philatlelphia Lying-In Hospital shows no case of chorionepithelioma following a full-term pregnancy. All cases of chorionepithelioma recorded followed abortions or hydat,idiform moles. Mrs. M. D., aged twenty-nine, first consulted me when she was approximately three months pregnant. She wds a nulliparous patient who had had influenza in 1918, tonsillectomy in 1926, and an appendectomy in 19% There were no other serious illnesses or operations. Her periods haul been established at the age of fourteen; had always been regular ; normal in amount and duration. Her last period was Dec. 26, 1933, and her expected date of confinement, Oct. 2, 1934. This patient, was seen with regularity during the rest of her pregnancy, and at no time had any disturbing symptoms more than the usual discomfort associated with pregnancy. Her blood pressure, urine, and other findings remained essentially normal. She was admitted to the Lying-In Hospital private service on Oct. 5, 1934. Her pains began at 5 P.M. and at the time of admission, were approximately five-minute intervals, lasting from twenty to thirty seconds. Fetal heart sounds were heard in the right lower quadrant and were of good quality. The blood pressure was 116/50.
C
*Presented
at
a meeting
of the
Obstetrical
Society
of Philadelphia.
May
2. 193.5.
LULL
:
CHORIONEPITHELIOMA
731
Labor progressed normally and at 9 P.M. she was given vi gr. nembutal and I/150 gr. of scopolamine. The scopolamine was repeated at 1 A.M. Analgesia was good, and at 4:30 A.M., Oct. 6, 1934, the head was presenting at the vulva in R.O.A. position. Under light gas anesthesia, a median episiotomy was done and the head was lifted off the perineum. Duration of gas anesthesia was twenty minutes. The third stage was uneventful, the placenta being delivered sixteen minutes after the baby. The usual ernutin and infundin were given. The child was normal and was sent to the nursery in good condition. The patient’s puerperal period was uneventful. At no time during her confinement to the hospital, which lasted eleven days, was there any elevation of temperature or pulse. The perineum healed immediately and the lochial Both mother and child were discharged in discharge was normal on all occasions. good condition on Oct. 17, 1934. The patient was told to report for follow-up examination in four weeks, and her postpuerperal care was outlined before discharge. The subsequent convalescence was normal until Nov. 7, when the patient began to bleed rather freely. She was put to bed, oxytoxic drugs were administered together with sedatives, ancl in two or three days the bleeding stopped. No pelvic examination was made at that time. The patient again resumed her household duties which were limited to caring for the chihl and very minor household details. On the thirteenth of November a sudden hemorrhage occurred, which was severe. She was immediately hospitalized, and ut the time of admission she was in very slight shock. Intravenous injection of glucose together with stimulation was ordered, and the vagina packed temporarily. Six hours later, when the pulse and temperature were normal, she was taken to the operating room and under light gas anesthesia the vaginal packing was removed. The cavity of the uterus was explored with a blunt placental forceps and a few small shreds of decidual tissue removed. Examination under anesthesia showed involution of the uterus to be normal, and no adnexal masses. The uterus was packed, together with the vagina, and the patient returned to her room in good condition. The bloo,d couut the following day showed 64 per cent hemoglobin and 3,000,OOO red cells. The packing was remove11 at the end of thirty six hours. There was no further blreling and on November 22, she was discharged in good condition. While in the hospital her secondary anemia was actively treated. She remainetl in bed from the time of her discharge and was not seen until November 39, one week later. At that time her pulse was running between 90 and 100, and her temperature was normal. But during the entire week at home there had been a slight bright red bloody discharge. As this seemed to be rather unusual, she was again admitted to the hospital, and examined umler nitrous oxide anesthesia (this patient was very difficult to examine without an anesthetic). During the course of the examinat,ion there was a spurt of bright red blood from the uterus, SO that the uterus was again packed to c.ontrol the bleeding. The examination revealetl no pathology that was palpable in the pelvis and the uterus was well involuted. Chorionepithelioma was suspected and a Friedman test taken at this time was shown to be positive in dilutions of 1 to 20. The quite typica elevation of temperature occurred the following day and immediate operation was postponed while the patient was given transfusions and other supportive treatment. There was no further hemorrhage when the packing was removed. Five days later, in spite of an elevation of temperature and pulse, under light nitrous oxide and ether anesthesia, the abdomen was opened. The uterus was small Over the right born there was a slight adhesion between the omeutum and firm. and the peritoneal covering of the uterus. Upon lifting the omentum up, a small area about one-fourth inch in diameter w’as found with a bluish discoloration, and the peritoneal covering of the uterus almost perforated. Panhysterectomy was done as rapidly as possible and the patient left the operating room in good condition. Post-
732
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGT
operative convalescence until December 23, was more or loss uneventful. The temperature receded and the pulse came domu to about DO. Thr mounll he&d by primary union, and there was no unusual ahdon~inal symptoms. On December 30, sixt,een days :lftc:, Ilpcration, the telnp!lxturc! was 1ror1d and the pulse 96. On December 31 the patittnt hrgnn to cough and had definite pulmonary signs. X-ray of the chest on Jan. ::, 19:X, 11y Dr. I’aul Bishop, showed a greaat &~a1 of mottled infiltration throughout lrtrth lungs, but more extcsnsive on the right side and especially marker1 at the right h:rsc). Flis opinion WIR that this was a mctastatic lesion. Reexamination tm J:mu:~ry S sl io\i.t’~l in (listiuc:t incrcast, in amount of lung infiltration. Dr. Hishop’s opinion was tlmt the major portion 01’ the pulmonary lesions was mc+astatic in origin. Pntic,nl ‘s condition l)ec:rnl~~ n~nduallv y worse and by January 11, hat1 tlefinitt, signs of mc~tastasis to the t;r:iin. Death occurred on Jan. 13, 1935. A2rit~~psy wis not per~nittwl. Pathologic examination by Dr. .John l<:au~r showell the uterus to be normal esceld in the region just antcsrior to t 11~1 I igIlt 11or11 \vhc~ till> ~rfa~e was of a (lark reddish blue color and the tis~nc ~lt+litc~ly fatty. I1 en’ :tlso there were trvo hemispherical norlules projecting xl~rvr~ tIlti> .;urfacr of the oqun. One of these nodules, the smaller, was s mn~. in Ircight an11 mc~snr~~l 12 mm. in Iliameter. The top was very soft ant1 llrown as thoriqli necrotic. ThcBre was also :I firm pinkish nodule 4 mm. in height and tli:mit:tc:r 1Irujrc’t in,g frown thr upper surface of the right tube just proximal to its fimbristc~l cn~l. Tllc mucosa of the Vrrvix am1 of tlicl lowrl third of the uterus was not n~:rl in apprar~~nc~. 11 ic.rosalrpic c*Yanrination showed a typical chorioncpitheliomu. 1731
PINE
STRKET
SPONTANEOUS
EVOL~‘TTOS 01‘ PRP?tFYTATTOK* ,L i*
A TRAIYSVERSE
T
RANSVERSE presentations arcs of tr~:asional ot’rurrence, the statistics showing that in about one case in 300, the shoul~ler presents. Transverse presentations which correct themselves spontaneously arc of cxct~e~linglp rar(s oc(-urrenc,l, this happening about once in 3,000 caws. The ease to be presented is of partirular int,erest in that the baby weighed 3,262 gm., t,his weight being exceeded in the eases in the literaturcx,, by that of Rusch 3,500 gm., and that of Herrgott X,300 gm. MorcoYcr, thrl cLntirt* mrchanism was completed in forty minutes.
Mrs. D., forty-two years old, Norwegian Hospital at 3 :00 AN., with the exception of the last, had The one abnormality was afebrile. of the membranes and subsequent The patient ‘s antrcrtl~~nt history case. Last menstrual perioll Kov.
a whittx female, para viii. was allmitt,ad to the Sept. S, 1923, in labor. Her previous pregnancies, all terminated spontaneously am1 each puerperium was a placenta previx latc’ralia, treated by rupture syontanaoun deliver)-. was essfmt,ially negative axul haul no bcariug on the ~‘:tl~ulntt~rl t (‘rL11, .1ug. 24, 1933. I$, 1932.
She had had no prenatal care? but Nixon tIlta onset of Iahl,r, at !I : (10 r.~r., local doctor who examined her vaginally, ruptured the mem!~ranes artificially, with obvious excitement,. told her that something was wrong. and suggested *Presented
at a meeting
of
the
Brooklyn
Gynecological
Society.
April
called her and then hospital5. 199.5.