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Endometrial ossification following an abortion
Volume
Number
130 5
Communications
locele. When the index patient had spina bifida, one of the 25 recurrent neural tube defects was also an encephalocele. In a normal gestation, the fetal head can usually be visualized ultrasonically by 14 weeks. We have seen it as early as nine weeks, and it is always seen at 16 weeks. Because of its spherical shape, smooth outline, and distinct acoustic differences from the surrounding amniotic fluid, it is the most easily seen part of the fetal body. At 16 weeks, the biparietal diameter is 3.4 cm. t 1 or 2 mm. The falx and lateral ventricles are clearly defined. Any deviation from this pattern should cause the examiner to suspect an abnormality. AFP elevation in amniotic fluid early in the second trimester is a well-established diagnostic test for families at high risk for neural tube defects.’ However, the elevation is dependent upon the defects being open to the amniotic fluid. The AFP level was in a normal range in our patient because the encephalocele was a closed defect. We would like to stress the efficacy of ultrasonography in the assessment of neural tube abnormalities. This technique is of particular diagnostic value when the defect is closed because AFP determinations are not helpful. We recommend that assessment of the fetal head and spine be included when ultrasound examination is being performed on any woman between 16 and 20 weeks’ gestation. It would be tragic to miss the opportunity for diagnosis of abnormalities in these structures at a time when families could exercise their option to terminate the pregnancy.
Fig. 1. Severe chronic endometritis tion. (Hematoxylin and eosin. x40.)
with
In brief
587
an area of calcilica-
REFERENCES
Mihmsky, .4., and Alpert, E.: The value of alphafetoprotein in the prenatal diagnosis of neural tube defects, J. Pediatr. 84: 889, 1974.
Miskin. M., Doran. T. A., Rudd, N., et al.: Use of ultrasound for placental localization in genetic amniocentesis, Obstet. Gvnecol. 43: 872. 1974. Carter, C. O., and Evans, K.: Spina bifida and anencephalus in greater London, J. Med. Genet. 10: 209, 1973.
HARRY Department Univevxity New York
WAXMAN, F.
vealed malignant cells and a colposcopically directed cervical biopsy showed later the patient vical conization.
M.D.
MOUSSOURIS,
M.D.
OSSIFICATION in the endometrium is a very rare finding.’ The common feature in most of the described patients is a previous history of abortion. We had an
000%9378/78/05130-0587$00.20/O
0
1978
Institute of PatholYork 11203. The C. V. Mosby
squamous underwent Carcinoma
cell carcinoma in situ. Two days dilatation and curettage with cerin situ with glandular involvement
was seen in the cervical tissue. The placental tissue was unre-
of Pathology, Kings County Has@al, State of New York, Downstate Medical Center, Brooklyn,
Reprint requests: Dr. Marian Waxman, ogy, 450 Clarkson Ave., Brooklyn, New
A 2%year-old woman, para 2-O-O-2, visited the outpatient clinic of Kings County Hospital on May 17, 1976, requesting an abortion. Her youngest child was three years old. Menstrual periods had always been regular, and the last menses was in February; 1976. She was found to be about two months pregnant. The cervical smear taken at this visit re-
Endometrial ossification following an abortion MARIAN
opportunity to examine a patient in whom endometrial bone formation was discovered exactly eight. weeks following an induced abortion. This may be the shortest period between the abortion and the discovery of the endometrial ossification yet described.
Co
markable. The patient was readmitted subsequently and she underwent a modified radical hysterectomy, exactly eight weeks following the abortion, on July 14, 1976. All the laboratory findings including serum calcium and inorganic phosphorus, were within normal limits at that time. The urinalysis. chest roentgenograms, and electrocardiogram were unremarkable. The patient was discharged from the hospital eight days later, following an uncomplicated postoperative course. The hysterectomy specimen appeared grossly normal. Microscopically, the cervix showed residual carcinoma in situ. The endometrium was secretory and displayed large areas of
588
Communications
in brief
March Am. J. Obstet.
1, 1978 Gynecol.
the inherent metaplastic properties of the mesenchyma1 cells that participate in the healing process. The endometrial bone formation thus described should be clearly set apart from a phenomenon of fetal tissues implanted in the uterus during curettage and subsequently found in the endometrium or endocervix. The tissues found in these cases have included bone, cartilage, muscle, and neuroglia. Roth and Taylor2 found only one case with foci of bone formation among their nine cases of heterotopic cartilage in the uterus, apparently unrelated to a previous abortion. They favored metaplasia of the stromal cells as the origin of the cartilage in their cases because of the finding of apparent transitional areas in three instances and because of the presence of acid mucopolysaccharides in the endometrial stroma adjacent to the cartilage.2 The appearance of mature bony spicules is easily distinguishable from that of malignant mixed Miillerian tumor or of teratoma. Their finding in the endometrial curettings should in no way cause contemplation of hysterectomy. The ossified fragments are most probably expelled with the menstrual discharge within several months, as apparently was the case in the patient described by Hsu.’
REFERENCES
Fig. 2. A fragment of mature bony spicule. (Hematoxylin eosin. x250.)
and
chronic and acute inflammation with polymorphonuclear leukocytic infiltration, necrosis, and homogeneous fibrinous deposits that resembled necrotic decidual fragments. Most prominent were multiple foci of calcilication and ossification, the latter consisting of mature bony spicules (Figs. 1 and 2). No cartilage or other heterotopic tissue was found. Endometritis is seen quite commonly in association with retained placental or decidual tissue after an abortion. Repeat curettings in these cases reveal devitalized, necrotic decidual fragments associated with heavy leukocytic infiltrate, a condition known as “postabortion endometritis.” The necrotic decidua -can be recognized microscopically by the presence of “ghosts” of the large decidual cells with prominent large nuclei. The latter eventually disappear and are replaced with homogeneous eosinophilic acellular tissue. The healing process is characterized by the development of granulation tissue and eventually fibrosis may ensue. Calcification and ossification developing in the old, healed inflammatory tissue, or in the area of an old hemorrhage, have long been recognized and examples such as ossification in atherosclerotic plaques, in lungs subjected to long-standing chronic passive congestion, or in old, healed granulomas abound. Ossification developing in the process of postabortion endometritis occurs, in our opinion, in the same manner, because of
1. Hsu, C.: Endometrial ossification, Br. J. Obstet. Gynaecol. 82: 836, 1975. 2. Roth, E., and Taylor, H. B.: Heterotopic cartilage in the uterus, Obstet. Gynecol. 27: 838, 1966.
Evaluation of fetal heart rate variability by a visual semiquantitative method and by a quantitative statistical method with the use of a minicomputer VEIKKO
KARINIEMI,
M.D.
I De@artment of Obstetrics and Gynecology, Central Hcxfital, Helsinki, Finland
Helsinki
University
HAMMACHER AND ASSOCIATES’ presented a semiquantitative method for evaluation of fetal heart rate (FHR) variability. Since then, many authors have demonstrated the importance of FHR variability as a means of assessing fetal well-being. It has proved valuable even when the rather inaccurate signals of ultrasound and phonocardiography are used for the recording. My associate and I* have recently reported a method
Supported by the Yrjo Jahnsson Foundation and the Finnish Medical Foundation. Reprint requests: Dr. Veikko Kariniemi, Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Haartmanink 2, 00290 Helsinki 29, Finland. 0002-9378/78/05130-0588$0030/O
0
1978
The C. V. Mosby
Co.
Number
130 5
Communications
locele. When the index patient had spina bifida, one of the 25 recurrent neural tube defects was also an encephalocele. In a normal gestation, the fetal head can usually be visualized ultrasonically by 14 weeks. We have seen it as early as nine weeks, and it is always seen at 16 weeks. Because of its spherical shape, smooth outline, and distinct acoustic differences from the surrounding amniotic fluid, it is the most easily seen part of the fetal body. At 16 weeks, the biparietal diameter is 3.4 cm. t 1 or 2 mm. The falx and lateral ventricles are clearly defined. Any deviation from this pattern should cause the examiner to suspect an abnormality. AFP elevation in amniotic fluid early in the second trimester is a well-established diagnostic test for families at high risk for neural tube defects.’ However, the elevation is dependent upon the defects being open to the amniotic fluid. The AFP level was in a normal range in our patient because the encephalocele was a closed defect. We would like to stress the efficacy of ultrasonography in the assessment of neural tube abnormalities. This technique is of particular diagnostic value when the defect is closed because AFP determinations are not helpful. We recommend that assessment of the fetal head and spine be included when ultrasound examination is being performed on any woman between 16 and 20 weeks’ gestation. It would be tragic to miss the opportunity for diagnosis of abnormalities in these structures at a time when families could exercise their option to terminate the pregnancy.
Fig. 1. Severe chronic endometritis tion. (Hematoxylin and eosin. x40.)
with
In brief
587
an area of calcilica-
REFERENCES
Mihmsky, .4., and Alpert, E.: The value of alphafetoprotein in the prenatal diagnosis of neural tube defects, J. Pediatr. 84: 889, 1974.
Miskin. M., Doran. T. A., Rudd, N., et al.: Use of ultrasound for placental localization in genetic amniocentesis, Obstet. Gvnecol. 43: 872. 1974. Carter, C. O., and Evans, K.: Spina bifida and anencephalus in greater London, J. Med. Genet. 10: 209, 1973.
HARRY Department Univevxity New York
WAXMAN, F.
vealed malignant cells and a colposcopically directed cervical biopsy showed later the patient vical conization.
M.D.
MOUSSOURIS,
M.D.
OSSIFICATION in the endometrium is a very rare finding.’ The common feature in most of the described patients is a previous history of abortion. We had an
000%9378/78/05130-0587$00.20/O
0
1978
Institute of PatholYork 11203. The C. V. Mosby
squamous underwent Carcinoma
cell carcinoma in situ. Two days dilatation and curettage with cerin situ with glandular involvement
was seen in the cervical tissue. The placental tissue was unre-
of Pathology, Kings County Has@al, State of New York, Downstate Medical Center, Brooklyn,
Reprint requests: Dr. Marian Waxman, ogy, 450 Clarkson Ave., Brooklyn, New
A 2%year-old woman, para 2-O-O-2, visited the outpatient clinic of Kings County Hospital on May 17, 1976, requesting an abortion. Her youngest child was three years old. Menstrual periods had always been regular, and the last menses was in February; 1976. She was found to be about two months pregnant. The cervical smear taken at this visit re-
Endometrial ossification following an abortion MARIAN
opportunity to examine a patient in whom endometrial bone formation was discovered exactly eight. weeks following an induced abortion. This may be the shortest period between the abortion and the discovery of the endometrial ossification yet described.
Co
markable. The patient was readmitted subsequently and she underwent a modified radical hysterectomy, exactly eight weeks following the abortion, on July 14, 1976. All the laboratory findings including serum calcium and inorganic phosphorus, were within normal limits at that time. The urinalysis. chest roentgenograms, and electrocardiogram were unremarkable. The patient was discharged from the hospital eight days later, following an uncomplicated postoperative course. The hysterectomy specimen appeared grossly normal. Microscopically, the cervix showed residual carcinoma in situ. The endometrium was secretory and displayed large areas of
588
Communications
in brief
March Am. J. Obstet.
1, 1978 Gynecol.
the inherent metaplastic properties of the mesenchyma1 cells that participate in the healing process. The endometrial bone formation thus described should be clearly set apart from a phenomenon of fetal tissues implanted in the uterus during curettage and subsequently found in the endometrium or endocervix. The tissues found in these cases have included bone, cartilage, muscle, and neuroglia. Roth and Taylor2 found only one case with foci of bone formation among their nine cases of heterotopic cartilage in the uterus, apparently unrelated to a previous abortion. They favored metaplasia of the stromal cells as the origin of the cartilage in their cases because of the finding of apparent transitional areas in three instances and because of the presence of acid mucopolysaccharides in the endometrial stroma adjacent to the cartilage.2 The appearance of mature bony spicules is easily distinguishable from that of malignant mixed Miillerian tumor or of teratoma. Their finding in the endometrial curettings should in no way cause contemplation of hysterectomy. The ossified fragments are most probably expelled with the menstrual discharge within several months, as apparently was the case in the patient described by Hsu.’
REFERENCES
Fig. 2. A fragment of mature bony spicule. (Hematoxylin eosin. x250.)
and
chronic and acute inflammation with polymorphonuclear leukocytic infiltration, necrosis, and homogeneous fibrinous deposits that resembled necrotic decidual fragments. Most prominent were multiple foci of calcilication and ossification, the latter consisting of mature bony spicules (Figs. 1 and 2). No cartilage or other heterotopic tissue was found. Endometritis is seen quite commonly in association with retained placental or decidual tissue after an abortion. Repeat curettings in these cases reveal devitalized, necrotic decidual fragments associated with heavy leukocytic infiltrate, a condition known as “postabortion endometritis.” The necrotic decidua -can be recognized microscopically by the presence of “ghosts” of the large decidual cells with prominent large nuclei. The latter eventually disappear and are replaced with homogeneous eosinophilic acellular tissue. The healing process is characterized by the development of granulation tissue and eventually fibrosis may ensue. Calcification and ossification developing in the old, healed inflammatory tissue, or in the area of an old hemorrhage, have long been recognized and examples such as ossification in atherosclerotic plaques, in lungs subjected to long-standing chronic passive congestion, or in old, healed granulomas abound. Ossification developing in the process of postabortion endometritis occurs, in our opinion, in the same manner, because of
1. Hsu, C.: Endometrial ossification, Br. J. Obstet. Gynaecol. 82: 836, 1975. 2. Roth, E., and Taylor, H. B.: Heterotopic cartilage in the uterus, Obstet. Gynecol. 27: 838, 1966.
Evaluation of fetal heart rate variability by a visual semiquantitative method and by a quantitative statistical method with the use of a minicomputer VEIKKO
KARINIEMI,
M.D.
I De@artment of Obstetrics and Gynecology, Central Hcxfital, Helsinki, Finland
Helsinki
University
HAMMACHER AND ASSOCIATES’ presented a semiquantitative method for evaluation of fetal heart rate (FHR) variability. Since then, many authors have demonstrated the importance of FHR variability as a means of assessing fetal well-being. It has proved valuable even when the rather inaccurate signals of ultrasound and phonocardiography are used for the recording. My associate and I* have recently reported a method
Supported by the Yrjo Jahnsson Foundation and the Finnish Medical Foundation. Reprint requests: Dr. Veikko Kariniemi, Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Haartmanink 2, 00290 Helsinki 29, Finland. 0002-9378/78/05130-0588$0030/O
0
1978
The C. V. Mosby
Co.