Hydatidiform mole and eclampsia with coexistent living fetus in the second trimester of pregnancy

CommunicaMns

the same exposure as conception, thus explaining acute gonococcal salpingitis associated with very early pregnancy. Also, one postulated barrier to ascent of infection, the obliteration of the endometrial cavity by the pregnancy, is not complete until the end of the first trimester, when the fusion of the decidua capsularis and the decidua parietalis occurs.* Thus, the gonococcus may ascend directly via the endometrial cavity, without direct interference with the pregnancy, until about 15 weeks from the patient’s last menstrual period. Bacteria may also ascend by lymphatic extension into the parametra, or produce a bacteremia, as evidenced by the association of gonococcal arthritis with pregnancy. This mechanism must also explain acute salpingitis occurring later in pregnancy. It is possible that cases of septic abortion in which patients deny interference with the pregnancy actually are caused by gonococcal infections leading to infected abortions. In previously reported cases of acute salpingitis in pregnancy, the gonococcus had never been recovered from the tubes. Other organisms isolated in these cases may have been secondary invaders in situations in which gonorrhea was not detected because of the fastidiousness of the organism, or because of the lack of currently available culture techniques. Nevertheless, the case reported here confirms the coexistence of acute gonococcal salpingitis and a 14 week intrauterine pregnancv which subsequently carried to term. REFERENCES

1. Acosta, A. A.,

Mabray, C. R., and Kaufman, R. H.: Intrauterine pregnancy and coexistent pelvic inflammatory disease, Obstet. Gynecol. 37: 282, 1971. 2. Hamilton, W. J., and Boyd, J. D.: Development of the human placenta, in Phillip, E. E., Barnes, J., and Newton, M., editors: Scientific Foundations of Obstetrics and Gynecology, Philadelphia, 1970, F. A. Davis Company, p. 204

Hydatidiform mole and eclampsia with coexistent living fetus in the second trimester of pregnancy BERNARD LESLIE

J.

SICURANZA,

HUGHES

M.D.

TISDALL,

M.D.

Department of Obstetrim and Gyrwcology, St. MaT’s Hos@al Division, Catholic Medical Center of Brooklyn and Queens, New York ECLA tidiform

MPSIA mole

occurring

in

is

too

not

the

presence

uncommon.

of hydaWe have

Reprint requests: Dr. Bernard J. Sicuranza, Department of Obstetrics and Gynecology, St. Mary’s Hospital Division, Catholic Medical Center of Brooklyn and Queens, Brooklyn, New York 11213.

in brief

513

been unable to find a case of this combination existing we felt rhe following with a living fetus.‘, ’ Accordingly. case was worthy of reporting. A 16-year-old black girl, gravida I-@(t-O, whose last menstrual period occurred on October 3, 1973. has admitted on February 6, 1974 with complaints of generalized wundsions, severe headache, and vomiting for 2 days prior to admission. The patient gave a history of recent vaginal bleeding for which she was seen in the emergencv room of another hospital and referred to the gynecologic clinic. There was no history of hypertension, epilepsy, headaches, epigastric pain, or visual disturbance. On admission, the patient was anxious and excitable but was in no acute distress. The pulse rate was 100 per minute* respirations 24 per minute, and the blood pressure 16O/lOO mm, Hg. A general physical examination was within normal limits. The uterus was 20 to 22 weeks in size, somewhat larger than the reported-period of gestation. The fetal heart was audible by Doptone. No other organomegaly t$as noted. The extremities revealed no edema; hyperreflexia was marked. The eye grounds showed a ratio of 3: 1 <%ith marked nicking. Two urinary chorionic gonadotropin tests were positive in titers of I-2048 and l-1716. The urinalysis revealed 4+ albumin and numerous granular casts. The &II. dehydrogenase was 301; serum glutamic oxalacetic transaminase, 148; serum glutamic pyruvic transaminase, ‘47. The, hemoglobin electrophoresis was A 49.2, S.45.4 AZ 4.7. ‘The chest x-ray revealed that the heart was slightly enlarged. An abdominal x-ray showed that the uterus was 20 weeks in silt with a single fetus. A diagnosis of molar pregnancy with rX iarnpsia and coexistent fetus was tnade. Treatment was initated with morphine artd magnesium sulfate, On February 5, 1974, a hysterotomy it as done with the delivery of a living male fetus, weighing 12.5 grams, who died shortly after birth. The patient had one more convulsion 4 hours after hysterotomy which was controlled with morphine and magnesium sulfate. She improvett steadily and was discharged 10 days later with a urinary rhorionic gonadotropin still positive. This gradually cleartad bv day 40 post partum. Serum gonadotropins were negative by the third month post parturn, The pathologic repot t stated that the maternal surface of the placenta showed Iat-ge chorionic villi with marked myxomatous changes. The diag~~osis was hydatidiform mole. This treated

patient was 16 years old. We h;tve recentl) two other patients who had mole ~.ith a living

fetus, but without eclampsia-one 16 years of age and the other 24. In Be&her’s’ series the average age was 24. He also reported hemorrhage in aboul 50 per cent of the cases. Our patient had minimal bleeding. The two other patients we managed had no bleeding. Onset of toxemia before week 28 of gestation has been the most consistent reliable diagnostic sign in these

cases.

While

eclampsia

was

present

in only

one

of

Beischer’s’ 92 cases of fetus with coexistent mole, 2 1 of’ these had fulminating toxemia. The present’e of a fetus is erroneously considered by some to rule out hydatidiform mole. The finding of a sit&e fetus is helpful since it excluded multiple gestation as a cause of early toxemia and eclampsia. The male : funale ratio

514

Communications

in brief

as reported is 1 : 3. The fetus in this case was male; the other two fetuses were female. This fetus was born alive but died shortly thereafter; our other two fetuses were stillborn. Beischer reported 54 stillborn and 38 live births with 19 survivors, Ultrasound was not used in our case as the convulsive state necessitated speed) resolution; however, it was disappointing in our other cases. One was reported as negative, and the other was inconclusive until the presence of a fetus was confirmecl by amniography. Ultrasound might be expected to help make the diagnosis but the molar transformation would have to be extensive for this to be made. With a coexistent fetus the molar transformation may be only minimal.’ A urinary chorionic gonadotropin level of 350,000 I.U. per liter, or a serum level of more than 320 I.U. per milliliter, after day 100, has been found to be consistently accurate in diagnosing the presence of a mole. Our patient had a titer of at least 3,000,OOO I.U. per liter of urine. Titers of greater than 350,000 I. U. per liter of urine were also present in our other two cases. It would seem, then, that in any case of toxemia with an early onset a titer of urinary chorionic gonadotropins should be done. It is an inex’pensivc and rapid test and would undoubtedly uncover manv cases without extensive molar transformation which might be missed at delivery. REFERENCES

I. Be&her, N. A.: Aust. N. 2. J. Obstet. Gynaecol. 6: 127. 1966. 2. Jones, m’. B., and Lauersen, M.D.: AM. J. OBSTET. GYNECOL.

122:

267,

1975.

latrogenic intravesical foreign body following Marshall-Marchetti procedure JAN

C.

SESKI,

M.D.

Department of Obstetrics und Gynecology, Uniwrsity Michigan Medical Center, Ann Arbor, Michigan

Ff

A VARIETY of surgical procedures have been developed over the years for the correction of stress incontinence in the female patient. Some of these have involved, in one form or another, a retropubic cystourethropexy as described by Marshall, Marchetti, and Krantz.’ Although modifications of the original hfarshall-Marchetti-Krantz operation have been proposed, the basis for its success rests upon an elevation and suture fixation of the vesical neck to a retropubic position. Various suture materials have been used to suspend the urethra and vesical neck to the symphysis pubis, cooper’s ligament, or rectus abdominis fascia. The suture materials used are either absorbable, as was described in the original Marshall-Marchetti-Krantz Reprint requests: Jan C. Seski, M.D., Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann ,4rbor, Michigan 48 104.

procedure, or nonabsorbable, as is suggested in SSIIIL' surgeons. Three representative cases of iatrogenic i~~travcsi~ ‘11 foreign bodv in the fk)rm of nonabsorbable 5111l~r(’ following h,iarshall-Marchetti-Krantz prwc(lurt. :UX presented. The able complication

diagnosis and are discussed.

C. C. was a 54-year-old

trcannent

of

thih

:tvoitl-

white wornan Gth a l~i~to~-y ot

recurrent urinary tract infections and s> mptoms of stress incontinence. Two years pt-eviously, she undrnwni a Xlarshall-Marchetti-Krantr procedure empkwing silk sutures Upon admission to the Medical Center. her urine \,a5 it)fected. An excretory urogram disclosed the presence of C~ 2 mm. intravesical calcification, and cystometry rewaled a pt-cviously undiagnosed uninhibited neruogenic bladder. C:v>toscopic examination found nvo stone-encrusted loops of silk protruding through the bladder mucosa, and these \$crc removed transurethrally with a biopsy forceps, Following this. the patient did well on a program of anticholinergic medic,ations and a frequenl voiding program. Her urge incontinence and recurrent nrinarv tract infection\ resolved. N. C. was a 32-year-old black woman with a long history ot repeated urinary tract infecCons which had increased ill frequency since a Marshall-Marchen-Krantz procedure ~a\ perform4 with nonabsorbable sutures. Her excretory urn,gram ~\as normal, but cystomett-v showed a large capacit! hladder. At the time of cystoswp). a Dacron suture in the superior aspect of the urinar? bladder \~as noted and retmoved transurethrall~ with a bwpsy forceps. On a program of frequent voiding, the patient has had no further urinary tract infections. Oral ephedrine stllfate had relieved her mild stress incontinence, K. L., a 44year-old w bite woman, underwem total ab. dominal hysterectomy and a Marshall-Marchetti-Krantz procedure; nonabsorbable sutures xvere employed it1 the suspension. Two months later, she complained of persistent frequency, d>suria, urge incontinence, and pyuria, Her CCcretor) urogram was unremarkable. Cvstoscopx examination found mulGpie ‘revdek (Deknatel Corp.) sutures in the bladder lumen surrounded bv marked inHammator> I-Csponse and bullous edema. I’he sutures vtere rcmo\ed transurethrall) with biopsy forceps. Since removal of the sutures, the patient’s symptoms ot urgency and urge incontinence have disappeared and hw urine has remained sterile.

‘rhe cases presented illustrate the hazards involved when permanent suture materials are employed in the Marshall-Marchetti-Krantz procedure. The high incidence of hematuria following this operation suggests that, more often than not, passed through the bladder

sutures

are

unkno~vingl\

II~WOS~.

Lapides’ has recommended that the suspension t)c accomplished by taking I cm. %ites” \vith absorbable chromic suture the sutures do

through not pull

the bladder $~a11 in order that through prematurely. If aI)sorbable sutures arc used and entry into the Hadder occurs, it still be of nt) consequence, provided that the intramural portion of the ureter is riot compr~~mised. Persistent irritative bladder symptoms, henwuria,