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Fetal death at term due to lightning
Volume Number
Communications
13-L I
Patient
in brief
103
A
Days Fig. 1. Duration
of symptoms
and viral quantitation
genital symptoms abated. Asymptomatic cervicovaginal shedding of HSV occurred at 4.5 and 7 months after initial infections. When asymptomatic viral shedding occurred, both patients denied exposure to multiple sexual partners or to partners with genital herpetic lesions. The titer of virus recovered during asymptomatic shedding in both patients was similar (2 log,, TCID,,, HSV/ml) and was less than that shed during primary infections. The mechanism of viral shedding is not clear. As all isolates were HSV 2, their courses are compatible with reactivation of latent infections or with reinfection. HSV serology was not performed on these women. These cases demonstrate that asymptomatic genital viral shedding occurs following acute vulvovaginitis. The quantity of virus shed during primary genital infection seems to be much higher than during subsequent asymptomatic viral shedding by the same individual. Additional studies of the patterns of genital viral shedding are necessary to delineate the epidemiology of this common venereal infection, since asymptomatic shedding due to either reactivation or reinfection may be important to the spread of genital HSV.
1.
REFERENCES Nahmias, A. J., Josey, W. E., Naih, Z. M., Lute, C. F., and
Duffey, A.: Antibodies to herpes 2 in humans, Am. J. Epidemiol. 2. Centifanto, Y. M., Hifdebrandt,
man, H. E.: Relationship tion
and
OBSTET.
carcinoma GYNECOL.
virus hominis types 1 and 91:539, 1970. R. J., Held, B., and Kauf-
of herpes simplex genital infec-
of cervix: Population 110:690, 197 1.
studies.
AM. J.
in two patients
with genital
herpes
simplex
virus.
Ekwo, E. E., and Myers, M. G.: Tampon culture for quantitation of cervicovaginal herpes simplex virus, Virol. 2:1, 1978. Pa&, F. P., and Dowdle, W. R.: A serological herpes virus hominis strains by microneutralization
J.
Med.
study of tests, J.
Immunol. 98:941, 1967. Deardourff,
S. L., Deture,
F. A., Drylie,
D. M., Centifano,
Y., and Kaufman, H.: Association between herpes hominis type 2 and the male genitourinary tract, J. Urol. 112: 126. 1974.
Fetal death at term due to lightning DILIP
K. GUHA-RAY,
F.R.C.S.(ENG.), United
M.B.,
B.S.,
M.R.C.O.G.
States Public
Health
Service,
Indian
Medical
Center,
Gallup, New Mexico INJURY to a gravid woman is a rare event. Several cases, with varied fetomaternal prognoses, have been reported.‘* ’ In only one case was there immediate cessation of fetal movements and subsequent stillbirth 3 to 4 months later.’ Another similar case is reported and the etiology, prevention, and feasibility of fetal revival in such circumstances are discussed. LIGHTNING
The opinions expressed in this article are those of the author and do not necessarily reflect those of the United Public Health Service or the Indian Health Service.
States
Reprint requests: Dr. Dilip K. Guha-Ray, Group Health Association, 20037.
2121
Pennsylvania
Ave.,
NW,
Washington,
D. C.
104
Table
Communications
I. Previously
Year
Author
in brief
reported Age Cyr)
cases
of’ lightning
injury
P&y
Ckstation (mo)
? Multip.
8
No. Knocked down
associated
Loss of coruciownesr
1833
Schieffer
?
1844
Alexander
?
;
7
No
1891 Ehertz
28
?
7
Yes
1906
Torggler
25
2
7
No. Fell off seat screaming
1959
Samsoenatjo
22
2
6+
Yes
1965
Rees
25
?
2+
Yes. Knocked down
1972
Chan and Sivasamhoo
29
G2 P?
Term
Yes
1972
Chan and Sivasamboo
19
Cl
Term
No. Knocked down
PO
A 12-year-old Navajo Indian, gravida 1, para 0, came to Gallup Indian Medical Center at term on August 19. 1977, 2 days after being struck by lightning. While standing outdoors on a cloudy day, she was struck by lightning and was unconscious for 2 to 3 minutes until she was awakened by her relatives. Upon arousal she felt no further fetal movements. Examination revealed fetal death. Spider wave pattern suprficial burns were noted over the right palm, extending upward to the right axilla, and then descending along the right lateral chest wall and abdomen up to the right groin, with minimal involvement of the right lower quadrant of the abdomen. She had also a small area of superficial burn on her forehead above the right eyebrow. The burned areas healed spontaneously. Her past and family histories were unremarkable. She had no previous antenatal care. All routine antenatal investigations performed were within normal limits. Seven days later she went into labor spontaneously and was delivered of a macerated male fetus weighing 2,400 grams. The fetus and placenta grossly appeared normal. No autopsy study was performed.
with
pregnant:)
Burn
mm+\
Superficial: over left shoulder. chest, abdomen, legs Small superficial marks on left scapula
Superficial; right shoulder, arm, breast, abdomen: deeper; thigh Left scapula, along both sides of back, around abdomen to qymphysis pubis and down both legs Deep; 8-9 cm in diameter over abdomen. immediately below umbilicus Superficial: entry at back of neck, on riqht shoulder and ovel- lift mastoid region; exit burns; transversely ;I(,-ass buttocks Irregular patch of erythema 8 cm long with wheal on right hypochondrium and paraumbilical areas
Irregular linear areas of erythema with accompanying wheal on lateral aspect on right shoulder, right half of ventral ah.. dominal wall, and on medial aspect of righr thigh and over left eyebrow
Table 1 shows the in pregnant women.
reported The first
Normal living
delivery infant
at term
of
Motherand pregnancy remained normal next day. Further progress not reported Normal delivery of living infant at term Immediate cessation of fetal movements. Macerated stillbirth 3-4 mo later Rupture of uterus required immediate cesarean sectiolr; infant was dead hut mother survived Delivered normallv at term
Went into labor after accident and delivered 12*% hr later normally; infant was cyanosed at birth and died 15% hr after birth due to congestive cardiac failure Went into labor after accident; delivered normally of living infant 14 hr later
cases of’ lightning five cases were
injury reported
by Rees.’ Labor may be induced by the shock or the passage of high-voltage current through the uterus. In advanced pregnancy, lightning can also cause severe uterine contractions, resulting in rupture of‘ the uterus.’ However, no maternal death was noted in the literature. Both uterus and amniotic Ruid are thought to be good conductors of the electric current, which thus reaches the fetus, inducing cardiac arrest..l In adults, cardiac arrest is not infrequent Mowing lightning injury. Indefinite continuance of artificial resuscitation is advised, as frequently complete recovery is noted to occur after prolonged resuscitation. This is true because following lightning stroke the cessation of metabolism in all ceils, including brain cells, is so instantaneous that onset of the degenerative process is delayed. Cardiopulmonary arrest, with fixed and di-
Volume Number
Communications
134 1
lated pupils, frequently noted after lightning injury, and unlike other causes, should not be taken as an indication of cerebral death. Can a fetus in utero be affected in such manner as well (after the mother had been struck b’y lightning)? Is it possible to resuscitate such a fetus in utero? Perhaps cardiac arrest can be produced experimentally in a fetus in utero by electric shock, followed by an attempt to resuscitate that fetus. If successful, this resuscitation procedure could be made applicable to the human fetus in utero. This could be an exciting field to study and much knowledge might be added to perinatology. The following preventive measures are recommended when lightning threatens: if outdoors, remove all metal pieces from the head; lie flat or crouch down; move to a safer place-if possible, to a building in the immediate vicinity or to a grove of trees but never a lone tree (lightning bolts frequently strike tall lone trees). Do not remain in water if swimming or boating. If in a car, other than a convertible, stay inside. In a building, the :safest place is in the basement; stay away from open doors, windows, telephone, radiators, fireplace, TV, radio, lamps, and other electric equipment; avoid washing dishes or taking showers or baths. REFERENCES 1.
Rees, W. D.: Pregnant Med.
J. 1:103,
woman
struck
by lightning,
2. Chan, Y.-F., and Sivasamboo, R.: Lightning pregnancy, 1972.
Br.
1965.
J. Obstet.
Gynaecol.
Br.
accident in
Commonw.
79~761,
RALPH J. WYNN, M.D. RICHARD L. SCHREINER,
KUB demonstrated multiple loops of distended bowel with massive ascites. No intraperitoneal calcifications were noted. An abdominal paracentesis was performed for the relief of
genital
M.D.
gravida 2, para 0, abortus 1, A-Rh was noted at 34 weeks’ gestation to
@ 1979
with
perfo-
and hemolytic workup were negative. She died at 7 months of age. At postmortem examination there were no other con-
Reprint requests: Ralph J. Wynn, M.D., Pediatrics, Children’s Hospital of Buffalo, Buffalo, New York 14222.
0002-9378/79/090105+02$00.20/0
peritonitis
120 cc
distal ileum and a 10 cm duplication of the small intestine were resected. Postoperatively the hemoglobin stabilized and the reticulocyte count fell to normal values. A TORCH screen
L I LE Y 1 H A s cautioned obstetricians of a variety of potential errors in the assessment of amniotic fluid for hemolytic disease of the newborn infant. A case is presented of an elevated amniotic fluid bilirubin level, without evidence of hemolytic disease, in a woman with acute hydramnios. The infant was found to have had an in utero intestinal obstruction. woman, negative,
Approximately
ration, volvulus, and atresia of the distal ileum. The necrotic
Department oj‘Pediat&, Indiana University School of Medicine, anal James Whitcomb Riley Hospital for Children, Indianapolis, Indiana
A 35-year-old negative, VDRL
105
have gained only 5 kg over her prepregnancy weight; her uterine fundus was that of a 26 week gestation. An antibody screen was negative. An ultrasound at that time demonstrated a biparietal diameter compatible with a 35 week gestation fetus. During the following week she noted increasing abdominal girth and abdominal tenderness. On examination she was noted to have gained 6 kg. Her blood pressure was unchanged and there was no proteinuria. Sonography revealed hydramnios. X-ray of the abdomen revealed no evidence of fetal skeletal anomalies. Liver, renal, and clotting function studies were normal. A 2 hour postprandial blood sugar was normal. A repeat screen for atypical antibodies was negative and a Betke-Kleihauer stain revealed no evidence of fetal-maternal transfusion. An amniocentesis revealed yellow amniotic fluid, shake-test positive, delta O.D. 0.404 (high upper zone). Alpha fetoprotein and viral cultures were negative. A primary cesarean section was performed under general anesthesia with an estimated 3,500 cc of yellow fluid noted. The placenta weighed 750 mg without evidence of pathologic change. A female infant, weighing 2,900 grams, at 35 to 36 weeks’ gestation by examination, with Apgar scores of 1 and 4 at 1 and 5 minutes, respectively, was born. The infant was pale, with massive ascites and minimal peripheral edema. She required mechanical ventilation. The CBC revealed a hemoglobin of 8.6 gm/dl, reticulocyte count of 16.2%. RBC morphology normal, and platelet count 40,000/mm.3 The serum bilirubin was 1.7 mg/dl total, the total protein 4.3 gm/dl, the blood type A-Rh positive, and direct Coombs negative. A
respiratory compromise and diagnosis. of brown fluid were obtained. At laparotomy there was meconium
Spurious elevation of amniotic fluid bilirubin in acute hydramnios with fetal intestinal obstruction
in brief
The
Department 219 Bryant
C. V. Mosbv
of St.,
Co
anomalies.
While hydramnios may occur in up to 1 to 2% of all pregnancies, acute hydramnios is uncommon. It is often associated with uniovular twin pregnancy. When found in singleton pregnancies it is frequently associated with concealed intrapartum hemorrhage or fetal congenital anomalies. Gastrointestinal obstruction is second only to anencephaly as a fetal anomaly resulting in hydramnios.’ Amniocentesis has been advocated in the management and diagnosis of acute hydramnios. Liley’ noted that the 450 pm absorption peak of amniotic fluid may be enlarged misleadingly by contamination with the heavily pigmented serum of an affected fetus, by the presence of meconium, or by the regurgitation of bile in the case of obstruction of the alimentary tract distal to the papilla of Vater. Intestinal atresia has been diagnosed in utero by the
Communications
13-L I
Patient
in brief
103
A
Days Fig. 1. Duration
of symptoms
and viral quantitation
genital symptoms abated. Asymptomatic cervicovaginal shedding of HSV occurred at 4.5 and 7 months after initial infections. When asymptomatic viral shedding occurred, both patients denied exposure to multiple sexual partners or to partners with genital herpetic lesions. The titer of virus recovered during asymptomatic shedding in both patients was similar (2 log,, TCID,,, HSV/ml) and was less than that shed during primary infections. The mechanism of viral shedding is not clear. As all isolates were HSV 2, their courses are compatible with reactivation of latent infections or with reinfection. HSV serology was not performed on these women. These cases demonstrate that asymptomatic genital viral shedding occurs following acute vulvovaginitis. The quantity of virus shed during primary genital infection seems to be much higher than during subsequent asymptomatic viral shedding by the same individual. Additional studies of the patterns of genital viral shedding are necessary to delineate the epidemiology of this common venereal infection, since asymptomatic shedding due to either reactivation or reinfection may be important to the spread of genital HSV.
1.
REFERENCES Nahmias, A. J., Josey, W. E., Naih, Z. M., Lute, C. F., and
Duffey, A.: Antibodies to herpes 2 in humans, Am. J. Epidemiol. 2. Centifanto, Y. M., Hifdebrandt,
man, H. E.: Relationship tion
and
OBSTET.
carcinoma GYNECOL.
virus hominis types 1 and 91:539, 1970. R. J., Held, B., and Kauf-
of herpes simplex genital infec-
of cervix: Population 110:690, 197 1.
studies.
AM. J.
in two patients
with genital
herpes
simplex
virus.
Ekwo, E. E., and Myers, M. G.: Tampon culture for quantitation of cervicovaginal herpes simplex virus, Virol. 2:1, 1978. Pa&, F. P., and Dowdle, W. R.: A serological herpes virus hominis strains by microneutralization
J.
Med.
study of tests, J.
Immunol. 98:941, 1967. Deardourff,
S. L., Deture,
F. A., Drylie,
D. M., Centifano,
Y., and Kaufman, H.: Association between herpes hominis type 2 and the male genitourinary tract, J. Urol. 112: 126. 1974.
Fetal death at term due to lightning DILIP
K. GUHA-RAY,
F.R.C.S.(ENG.), United
M.B.,
B.S.,
M.R.C.O.G.
States Public
Health
Service,
Indian
Medical
Center,
Gallup, New Mexico INJURY to a gravid woman is a rare event. Several cases, with varied fetomaternal prognoses, have been reported.‘* ’ In only one case was there immediate cessation of fetal movements and subsequent stillbirth 3 to 4 months later.’ Another similar case is reported and the etiology, prevention, and feasibility of fetal revival in such circumstances are discussed. LIGHTNING
The opinions expressed in this article are those of the author and do not necessarily reflect those of the United Public Health Service or the Indian Health Service.
States
Reprint requests: Dr. Dilip K. Guha-Ray, Group Health Association, 20037.
2121
Pennsylvania
Ave.,
NW,
Washington,
D. C.
104
Table
Communications
I. Previously
Year
Author
in brief
reported Age Cyr)
cases
of’ lightning
injury
P&y
Ckstation (mo)
? Multip.
8
No. Knocked down
associated
Loss of coruciownesr
1833
Schieffer
?
1844
Alexander
?
;
7
No
1891 Ehertz
28
?
7
Yes
1906
Torggler
25
2
7
No. Fell off seat screaming
1959
Samsoenatjo
22
2
6+
Yes
1965
Rees
25
?
2+
Yes. Knocked down
1972
Chan and Sivasamhoo
29
G2 P?
Term
Yes
1972
Chan and Sivasamboo
19
Cl
Term
No. Knocked down
PO
A 12-year-old Navajo Indian, gravida 1, para 0, came to Gallup Indian Medical Center at term on August 19. 1977, 2 days after being struck by lightning. While standing outdoors on a cloudy day, she was struck by lightning and was unconscious for 2 to 3 minutes until she was awakened by her relatives. Upon arousal she felt no further fetal movements. Examination revealed fetal death. Spider wave pattern suprficial burns were noted over the right palm, extending upward to the right axilla, and then descending along the right lateral chest wall and abdomen up to the right groin, with minimal involvement of the right lower quadrant of the abdomen. She had also a small area of superficial burn on her forehead above the right eyebrow. The burned areas healed spontaneously. Her past and family histories were unremarkable. She had no previous antenatal care. All routine antenatal investigations performed were within normal limits. Seven days later she went into labor spontaneously and was delivered of a macerated male fetus weighing 2,400 grams. The fetus and placenta grossly appeared normal. No autopsy study was performed.
with
pregnant:)
Burn
mm+\
Superficial: over left shoulder. chest, abdomen, legs Small superficial marks on left scapula
Superficial; right shoulder, arm, breast, abdomen: deeper; thigh Left scapula, along both sides of back, around abdomen to qymphysis pubis and down both legs Deep; 8-9 cm in diameter over abdomen. immediately below umbilicus Superficial: entry at back of neck, on riqht shoulder and ovel- lift mastoid region; exit burns; transversely ;I(,-ass buttocks Irregular patch of erythema 8 cm long with wheal on right hypochondrium and paraumbilical areas
Irregular linear areas of erythema with accompanying wheal on lateral aspect on right shoulder, right half of ventral ah.. dominal wall, and on medial aspect of righr thigh and over left eyebrow
Table 1 shows the in pregnant women.
reported The first
Normal living
delivery infant
at term
of
Motherand pregnancy remained normal next day. Further progress not reported Normal delivery of living infant at term Immediate cessation of fetal movements. Macerated stillbirth 3-4 mo later Rupture of uterus required immediate cesarean sectiolr; infant was dead hut mother survived Delivered normallv at term
Went into labor after accident and delivered 12*% hr later normally; infant was cyanosed at birth and died 15% hr after birth due to congestive cardiac failure Went into labor after accident; delivered normally of living infant 14 hr later
cases of’ lightning five cases were
injury reported
by Rees.’ Labor may be induced by the shock or the passage of high-voltage current through the uterus. In advanced pregnancy, lightning can also cause severe uterine contractions, resulting in rupture of‘ the uterus.’ However, no maternal death was noted in the literature. Both uterus and amniotic Ruid are thought to be good conductors of the electric current, which thus reaches the fetus, inducing cardiac arrest..l In adults, cardiac arrest is not infrequent Mowing lightning injury. Indefinite continuance of artificial resuscitation is advised, as frequently complete recovery is noted to occur after prolonged resuscitation. This is true because following lightning stroke the cessation of metabolism in all ceils, including brain cells, is so instantaneous that onset of the degenerative process is delayed. Cardiopulmonary arrest, with fixed and di-
Volume Number
Communications
134 1
lated pupils, frequently noted after lightning injury, and unlike other causes, should not be taken as an indication of cerebral death. Can a fetus in utero be affected in such manner as well (after the mother had been struck b’y lightning)? Is it possible to resuscitate such a fetus in utero? Perhaps cardiac arrest can be produced experimentally in a fetus in utero by electric shock, followed by an attempt to resuscitate that fetus. If successful, this resuscitation procedure could be made applicable to the human fetus in utero. This could be an exciting field to study and much knowledge might be added to perinatology. The following preventive measures are recommended when lightning threatens: if outdoors, remove all metal pieces from the head; lie flat or crouch down; move to a safer place-if possible, to a building in the immediate vicinity or to a grove of trees but never a lone tree (lightning bolts frequently strike tall lone trees). Do not remain in water if swimming or boating. If in a car, other than a convertible, stay inside. In a building, the :safest place is in the basement; stay away from open doors, windows, telephone, radiators, fireplace, TV, radio, lamps, and other electric equipment; avoid washing dishes or taking showers or baths. REFERENCES 1.
Rees, W. D.: Pregnant Med.
J. 1:103,
woman
struck
by lightning,
2. Chan, Y.-F., and Sivasamboo, R.: Lightning pregnancy, 1972.
Br.
1965.
J. Obstet.
Gynaecol.
Br.
accident in
Commonw.
79~761,
RALPH J. WYNN, M.D. RICHARD L. SCHREINER,
KUB demonstrated multiple loops of distended bowel with massive ascites. No intraperitoneal calcifications were noted. An abdominal paracentesis was performed for the relief of
genital
M.D.
gravida 2, para 0, abortus 1, A-Rh was noted at 34 weeks’ gestation to
@ 1979
with
perfo-
and hemolytic workup were negative. She died at 7 months of age. At postmortem examination there were no other con-
Reprint requests: Ralph J. Wynn, M.D., Pediatrics, Children’s Hospital of Buffalo, Buffalo, New York 14222.
0002-9378/79/090105+02$00.20/0
peritonitis
120 cc
distal ileum and a 10 cm duplication of the small intestine were resected. Postoperatively the hemoglobin stabilized and the reticulocyte count fell to normal values. A TORCH screen
L I LE Y 1 H A s cautioned obstetricians of a variety of potential errors in the assessment of amniotic fluid for hemolytic disease of the newborn infant. A case is presented of an elevated amniotic fluid bilirubin level, without evidence of hemolytic disease, in a woman with acute hydramnios. The infant was found to have had an in utero intestinal obstruction. woman, negative,
Approximately
ration, volvulus, and atresia of the distal ileum. The necrotic
Department oj‘Pediat&, Indiana University School of Medicine, anal James Whitcomb Riley Hospital for Children, Indianapolis, Indiana
A 35-year-old negative, VDRL
105
have gained only 5 kg over her prepregnancy weight; her uterine fundus was that of a 26 week gestation. An antibody screen was negative. An ultrasound at that time demonstrated a biparietal diameter compatible with a 35 week gestation fetus. During the following week she noted increasing abdominal girth and abdominal tenderness. On examination she was noted to have gained 6 kg. Her blood pressure was unchanged and there was no proteinuria. Sonography revealed hydramnios. X-ray of the abdomen revealed no evidence of fetal skeletal anomalies. Liver, renal, and clotting function studies were normal. A 2 hour postprandial blood sugar was normal. A repeat screen for atypical antibodies was negative and a Betke-Kleihauer stain revealed no evidence of fetal-maternal transfusion. An amniocentesis revealed yellow amniotic fluid, shake-test positive, delta O.D. 0.404 (high upper zone). Alpha fetoprotein and viral cultures were negative. A primary cesarean section was performed under general anesthesia with an estimated 3,500 cc of yellow fluid noted. The placenta weighed 750 mg without evidence of pathologic change. A female infant, weighing 2,900 grams, at 35 to 36 weeks’ gestation by examination, with Apgar scores of 1 and 4 at 1 and 5 minutes, respectively, was born. The infant was pale, with massive ascites and minimal peripheral edema. She required mechanical ventilation. The CBC revealed a hemoglobin of 8.6 gm/dl, reticulocyte count of 16.2%. RBC morphology normal, and platelet count 40,000/mm.3 The serum bilirubin was 1.7 mg/dl total, the total protein 4.3 gm/dl, the blood type A-Rh positive, and direct Coombs negative. A
respiratory compromise and diagnosis. of brown fluid were obtained. At laparotomy there was meconium
Spurious elevation of amniotic fluid bilirubin in acute hydramnios with fetal intestinal obstruction
in brief
The
Department 219 Bryant
C. V. Mosbv
of St.,
Co
anomalies.
While hydramnios may occur in up to 1 to 2% of all pregnancies, acute hydramnios is uncommon. It is often associated with uniovular twin pregnancy. When found in singleton pregnancies it is frequently associated with concealed intrapartum hemorrhage or fetal congenital anomalies. Gastrointestinal obstruction is second only to anencephaly as a fetal anomaly resulting in hydramnios.’ Amniocentesis has been advocated in the management and diagnosis of acute hydramnios. Liley’ noted that the 450 pm absorption peak of amniotic fluid may be enlarged misleadingly by contamination with the heavily pigmented serum of an affected fetus, by the presence of meconium, or by the regurgitation of bile in the case of obstruction of the alimentary tract distal to the papilla of Vater. Intestinal atresia has been diagnosed in utero by the