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Hysterography in the diagnosis of dead and retained human ovum
HYSTEROGRAPHY
IN
THE
DIAGNOSIS OF DEAD HUMAN OVUM
AND
RETAINED
M.D., AKVIANDOE. NOGIJBS, MI)., ASD M.D.. HIJEXOS AIRES, ARGESTIN.~
JU‘%ZNC. AHUMMLI,
CORNELIO DONOVAN, (From
(‘atdrn
dc
C’linica
Gineco7ogicrc
dc Hut
no.3 Aires)
N PATIENTS in whom the ovisac is not eliminated from the uterus within ;I certain period of time after the embryo has ceased to be \:iahle, we prefer to speak of the dead and retained human tovum instead of missed ahortiou.‘“. ” The diagnosis of this condition is difficult in some patients. Jn addition to those patients in whom t,he diagnosis of pregnancy is correctly made and in whom deat,h of the embryo may br proved by the lack of uterine growth, absence of fetal motility, and negative pregnancy tests, there is a group of patients in whom the diagnosis of pregnancy has not been clinically and biologically proved. Tn the latter group? in order to avoid diagnostic mist,akes. painstaking studies should be made. Jf these patient,s are not correctly st,ndied they may receive incorrect and unfortunate treatment, especially sinc*c Ihtse individuals arc generally young women. In one of’ our cases, for cxamI)le. the wrong diagnosis led to a subtotal hysterectomy ; in another, complete esamination as well as h>-st-rrography prevented such a mist,ake. Several different ways of demonstrating death of the ovum iI1 utcarc~ha\-ch heen tried. Zondek and associates’” use the test of ovarian congestion protlnced by human urinary gonadotrophin ; this test \vouItl be negat.iT,cnil f’t,cll fetal deat,h. Spielman, (:oldberger. and J-Yank’ acac*eipt as of significance thr drop in the blood estrogen level under the same conditions. I~altli” has t~ceommendttl puncture of the amniol ic SR.Pand examination of it,s fluid. Thr Iiistaniinolitic index in the maternal blootl is used bj- \-iltl den Drirsschcl~ who hns found a 20 per cent drop after tlciith of the o~uti1 in utc~ro. 1&4ti~olo’~ st ltdicd the maternal calotting time whic~h IIC found to IW accelcra.tcd a t’f(lr rl~th of’ the embryo occurred. The diagnosis by x-ray examination oi’ death of the embryo in l1tct.o kvas first used by ILorner” in 1921. The results from s-ra>- examination arc positivc* only in advanced pregnancies in which the fetus is observable: one nlay Ilot-c> relaxation of the fetal skeleton, collapse of the skull bones, overriding of the bones, ct,c. Before the fourth or fifth month of pregnancy, t,he rchsults f’rolll x-ray examination arc very poor and the clinical findings are not sufici~~nt fat a definite dia.gnosis. Tinclcr these c~irclunst;rnc’rlsWC ha~a nsed hystcrograph>with satisfactory results. The x-ray pictures of the dead and retained ovum have a particular characteristic which makes diagnosis possible. The final diagnosis, however, is made I
12T4
from an esaminat,ion of the roentgenogram and due considcrat,ion of the clinic31 history. The changes noted in the uterus as reflected in the hysterogram arc! due to t,wo conditions: first, the changes in the myometrium and, second, thv influence of thr dead embryo within the uterus. The utrrine cavity shows dcI’ectivc filling and a lobulated outline within the limits of an abnormal shatlow. The h~xtcrogram discloses an enlarged uterine cavity, which varies in shapc~ according to the site of implantation of the ovum. JVhvn the implantation site is in the I’undus, the uterus takes on the shape of a fi p, due to tl1c fact t11nt lllkb wrvieal and ist hmic portions of the uterus are not involved in the total ~llii11$Y’S. \Vlicn the implantation silt is on the lateral wall! tlic uterus ;ISSIII~S a 1~011~1~1~~1 shape.
Fig.
cavity, lobulations.
the
l.-Hysterogram incomplete
filling
is patient in the
with fumlus
death at
of the
ovum in utero. site of implantation,
Kote
the and
larse fi~-rl~~~~l the well-
\\‘lien tlicl clift’crcntial (liagnosis is considered, it slio~dd be borne in ttriml that neithrr submucous myomas r101’ sarco1na.s produce a lobulated hystrrographic picture. In the case uf uterine ear&oma, the irregular outline iIllt1 the ragged limits of thr hysterogl’:ltll are t,ypical and there should lw no possibility of confusion. JYhen WP speak ;lbout the differential diagnosis WC refer only to pictures tilltell wit,11 ilC[llPClllS l*ildiopaql~e solutions.
Material 11-e have presented clata in our cases.
in Table 1 il rdsnm6
of the most iml)o&nt
rlinical
2
l~llklll~\!‘ll
I Irregular rhagia. cYlrettagr
mct,rorPrevious
3
4
.\nlcllOtl4lc?a
plus mctror-
regular rhigia 4
36
6
~\nlcnorrhca. nlctrorrhagia
plus
5
33
10
.knlc~norrllea mctrorrhagia months
plus for
6
43
7
z\rncnorrhea 4 months, t,hen Inctrorrhagia
5
33
3
A tncnorrhea mctrorrhagia month
8
“8
!I
irregular rhagia. followed rhngia ~\nllworrlrcYl mctrorrhxgia
plus for
plus for
10
II
I“ -
-..
3 7
5
1
nwtrorCbettagc by metror-
IlIOlltllS
I3
ir-
Pain anJ irregular nwtrnrrhngia.
2
Enlarged vavity, typi val irrrgular shadow
HYSTEROGRAPJ-JY
IS
DTAGNOSTS
OF
DEAD
HUMAX
OVUM
12i7
An incorrect interpretat,ion of the hysterographic findings in Patient 2 was Itlade, in view of which we were led to study systematically with s-ray c~saltrination all patients suspe&d of having a dea,d and retained ovum. The tenth l)atient listed in ‘l’al)le .l reeeivcd an incorrect tlisgnosis of SU~~UCOUS myoma and underwerlt a subtotal hysterectomy. Instead of a submucous myoma, a dead and retained ovum was found.
Comment Hysterography should not be performed unless death of the embryo is wrtiiin. This procc~du~x~ as shown ii) Fig. 1 has hem riscd iii our putknts wilhWC have not been able to confirm thr findings of omit any complications. ( ‘illll])OS da Paz” ot’ vawilar injection ol’ the contrast medium in the case of t.hc at onic* uterus and the occurrence of metrorrhagia in casts of partially eliminat,rd r~~hryos. We had no cases of septic complications. The hysterographic explorn1 ion of the uterus appears to act upon a poorly contracting nr\-onietrinm with priming c+f’rcts, thus improving the action of combined est,rogens and ox\-tacks 11sec1in the treatment of this condition.” The positive findings in hysterographic examination are : (1) The contrast medium acts upon an atcJnk wall enlarging the uterine cavity, thus 1)rotlucing an incomplete circular shadow, the boundaries of which arc the ut’erinr wall in the outer part and the fet,al membranes in the inner part.’ The injection of the contrast medium is ea.sily performed; at least 10 to 15 C.C. 01 the medium should be used. (2) The presence of the dead ovum in the ul~us prevents the formation of a complete and uniform shadow. Up to the second month of pregnancy the hysterogram has the characteristics previously clescribed. When the ovum has reached three or four months of agcb, the contrast medium is disposed around the ovum without going into the uterine caavity. With older ova, the cavity being occluded, the shadow does not have any characteristic pattern. The negative findings of diagnostic value are the exclusion of (1) the typical image in the case of submucous myoma or interst,itial myoma with suhmucous tendency. a most frequent. error; (2) endometrial polyp; (3) ader~onnyoqis; . L (4) endometrial hyperplasia; (5) cndometrial carcinoma. Tn each of these cases t.here are typical hysterographic characteristics .
Summary ITysterography is of great. value when there is a presumI)tive tliagnosis or a tleatl and retained OVIII~. It is a useful diagnostic procedure up to the roulth or fiFt.h month of pregnancy. Jt has no complications. The rndiopnque image is characteristic: the outer limits in contact with t,he uterine wall are incomplete ancl festooned; thr inner limits of the shadow resulting from cnnla(*t of the medium with the dead ovu~~~ are irregular in outline. The s-ray examination should not be made unless we are sure that, fetal death has taken place hecauw, in cases of gestation with a live embryo, it can casil?- lcad to an ilhot+ion.
IN
THE
DIAGNOSIS OF DEAD HUMAN OVUM
AND
RETAINED
M.D., AKVIANDOE. NOGIJBS, MI)., ASD M.D.. HIJEXOS AIRES, ARGESTIN.~
JU‘%ZNC. AHUMMLI,
CORNELIO DONOVAN, (From
(‘atdrn
dc
C’linica
Gineco7ogicrc
dc Hut
no.3 Aires)
N PATIENTS in whom the ovisac is not eliminated from the uterus within ;I certain period of time after the embryo has ceased to be \:iahle, we prefer to speak of the dead and retained human tovum instead of missed ahortiou.‘“. ” The diagnosis of this condition is difficult in some patients. Jn addition to those patients in whom t,he diagnosis of pregnancy is correctly made and in whom deat,h of the embryo may br proved by the lack of uterine growth, absence of fetal motility, and negative pregnancy tests, there is a group of patients in whom the diagnosis of pregnancy has not been clinically and biologically proved. Tn the latter group? in order to avoid diagnostic mist,akes. painstaking studies should be made. Jf these patient,s are not correctly st,ndied they may receive incorrect and unfortunate treatment, especially sinc*c Ihtse individuals arc generally young women. In one of’ our cases, for cxamI)le. the wrong diagnosis led to a subtotal hysterectomy ; in another, complete esamination as well as h>-st-rrography prevented such a mist,ake. Several different ways of demonstrating death of the ovum iI1 utcarc~ha\-ch heen tried. Zondek and associates’” use the test of ovarian congestion protlnced by human urinary gonadotrophin ; this test \vouItl be negat.iT,cnil f’t,cll fetal deat,h. Spielman, (:oldberger. and J-Yank’ acac*eipt as of significance thr drop in the blood estrogen level under the same conditions. I~altli” has t~ceommendttl puncture of the amniol ic SR.Pand examination of it,s fluid. Thr Iiistaniinolitic index in the maternal blootl is used bj- \-iltl den Drirsschcl~ who hns found a 20 per cent drop after tlciith of the o~uti1 in utc~ro. 1&4ti~olo’~ st ltdicd the maternal calotting time whic~h IIC found to IW accelcra.tcd a t’f(lr rl~th of’ the embryo occurred. The diagnosis by x-ray examination oi’ death of the embryo in l1tct.o kvas first used by ILorner” in 1921. The results from s-ra>- examination arc positivc* only in advanced pregnancies in which the fetus is observable: one nlay Ilot-c> relaxation of the fetal skeleton, collapse of the skull bones, overriding of the bones, ct,c. Before the fourth or fifth month of pregnancy, t,he rchsults f’rolll x-ray examination arc very poor and the clinical findings are not sufici~~nt fat a definite dia.gnosis. Tinclcr these c~irclunst;rnc’rlsWC ha~a nsed hystcrograph>with satisfactory results. The x-ray pictures of the dead and retained ovum have a particular characteristic which makes diagnosis possible. The final diagnosis, however, is made I
12T4
from an esaminat,ion of the roentgenogram and due considcrat,ion of the clinic31 history. The changes noted in the uterus as reflected in the hysterogram arc! due to t,wo conditions: first, the changes in the myometrium and, second, thv influence of thr dead embryo within the uterus. The utrrine cavity shows dcI’ectivc filling and a lobulated outline within the limits of an abnormal shatlow. The h~xtcrogram discloses an enlarged uterine cavity, which varies in shapc~ according to the site of implantation of the ovum. JVhvn the implantation site is in the I’undus, the uterus takes on the shape of a fi p, due to tl1c fact t11nt lllkb wrvieal and ist hmic portions of the uterus are not involved in the total ~llii11$Y’S. \Vlicn the implantation silt is on the lateral wall! tlic uterus ;ISSIII~S a 1~011~1~1~~1 shape.
Fig.
cavity, lobulations.
the
l.-Hysterogram incomplete
filling
is patient in the
with fumlus
death at
of the
ovum in utero. site of implantation,
Kote
the and
larse fi~-rl~~~~l the well-
\\‘lien tlicl clift’crcntial (liagnosis is considered, it slio~dd be borne in ttriml that neithrr submucous myomas r101’ sarco1na.s produce a lobulated hystrrographic picture. In the case uf uterine ear&oma, the irregular outline iIllt1 the ragged limits of thr hysterogl’:ltll are t,ypical and there should lw no possibility of confusion. JYhen WP speak ;lbout the differential diagnosis WC refer only to pictures tilltell wit,11 ilC[llPClllS l*ildiopaql~e solutions.
Material 11-e have presented clata in our cases.
in Table 1 il rdsnm6
of the most iml)o&nt
rlinical
2
l~llklll~\!‘ll
I Irregular rhagia. cYlrettagr
mct,rorPrevious
3
4
.\nlcllOtl4lc?a
plus mctror-
regular rhigia 4
36
6
~\nlcnorrhca. nlctrorrhagia
plus
5
33
10
.knlc~norrllea mctrorrhagia months
plus for
6
43
7
z\rncnorrhea 4 months, t,hen Inctrorrhagia
5
33
3
A tncnorrhea mctrorrhagia month
8
“8
!I
irregular rhagia. followed rhngia ~\nllworrlrcYl mctrorrhxgia
plus for
plus for
10
II
I“ -
-..
3 7
5
1
nwtrorCbettagc by metror-
IlIOlltllS
I3
ir-
Pain anJ irregular nwtrnrrhngia.
2
Enlarged vavity, typi val irrrgular shadow
HYSTEROGRAPJ-JY
IS
DTAGNOSTS
OF
DEAD
HUMAX
OVUM
12i7
An incorrect interpretat,ion of the hysterographic findings in Patient 2 was Itlade, in view of which we were led to study systematically with s-ray c~saltrination all patients suspe&d of having a dea,d and retained ovum. The tenth l)atient listed in ‘l’al)le .l reeeivcd an incorrect tlisgnosis of SU~~UCOUS myoma and underwerlt a subtotal hysterectomy. Instead of a submucous myoma, a dead and retained ovum was found.
Comment Hysterography should not be performed unless death of the embryo is wrtiiin. This procc~du~x~ as shown ii) Fig. 1 has hem riscd iii our putknts wilhWC have not been able to confirm thr findings of omit any complications. ( ‘illll])OS da Paz” ot’ vawilar injection ol’ the contrast medium in the case of t.hc at onic* uterus and the occurrence of metrorrhagia in casts of partially eliminat,rd r~~hryos. We had no cases of septic complications. The hysterographic explorn1 ion of the uterus appears to act upon a poorly contracting nr\-onietrinm with priming c+f’rcts, thus improving the action of combined est,rogens and ox\-tacks 11sec1in the treatment of this condition.” The positive findings in hysterographic examination are : (1) The contrast medium acts upon an atcJnk wall enlarging the uterine cavity, thus 1)rotlucing an incomplete circular shadow, the boundaries of which arc the ut’erinr wall in the outer part and the fet,al membranes in the inner part.’ The injection of the contrast medium is ea.sily performed; at least 10 to 15 C.C. 01 the medium should be used. (2) The presence of the dead ovum in the ul~us prevents the formation of a complete and uniform shadow. Up to the second month of pregnancy the hysterogram has the characteristics previously clescribed. When the ovum has reached three or four months of agcb, the contrast medium is disposed around the ovum without going into the uterine caavity. With older ova, the cavity being occluded, the shadow does not have any characteristic pattern. The negative findings of diagnostic value are the exclusion of (1) the typical image in the case of submucous myoma or interst,itial myoma with suhmucous tendency. a most frequent. error; (2) endometrial polyp; (3) ader~onnyoqis; . L (4) endometrial hyperplasia; (5) cndometrial carcinoma. Tn each of these cases t.here are typical hysterographic characteristics .
Summary ITysterography is of great. value when there is a presumI)tive tliagnosis or a tleatl and retained OVIII~. It is a useful diagnostic procedure up to the roulth or fiFt.h month of pregnancy. Jt has no complications. The rndiopnque image is characteristic: the outer limits in contact with t,he uterine wall are incomplete ancl festooned; thr inner limits of the shadow resulting from cnnla(*t of the medium with the dead ovu~~~ are irregular in outline. The s-ray examination should not be made unless we are sure that, fetal death has taken place hecauw, in cases of gestation with a live embryo, it can casil?- lcad to an ilhot+ion.