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Massive ovarian edema
346
Communications
dicate umbilical lemia would effects
June 1. 1981 Am. J. Obstet. Gynecol.
in brief
fetal
hemodynamic adaptation to partial chronic vein compression. leading to relative hypovoand oliguria in utero. Chronic fetal oliguria explain the uligohydramnios seen here. Furthet on amniotic fluid volume, such as prevention of
egress of lung fluid via the laryngeal outlet, could be anticipated from compression of the fetal neck. Swallowing of amniotic fluid might also be reduced, but to a lesser degree, since the anatomically deeper esophagus was relatively protected from the external constriction band of‘ the nuchal cord. REFERENCES
1. Bruce, S., James, L. S., Bowe, E., et al.: Umbilical cord complications as a cause of perinatal morbidity and mortality. J. Perinat. Med. 6:89, 1978. 2. Sadovsky, E.. Weinstein. D.. Aboulafia, Y., et al.: Decreased fetal movements associated with umbilical cord complications, Isr. .J. Med. Sci. 13:295, 1977.
Massive ovarian edema JEROME G.
ABRAMS,
H.
Departments Muhlenberg THE
M.D
SALALAR.
eventfill.
of Obstetrics Hospital,
and Gynecology and Patholoa, Plainjield, New Jersq
ovarian
here edema
Reprint requests: Dr. Obstetrics and Gynecology, New Jersey 0706 1.
represents encountered
10346+02$00.2010
an
example
3 years
of before
Jerome Abrams. Department of Muhlenberg Hospital, Plainfield,
Fig. 0002-9378/81/l
A 25-year-old white woman, gravida 3, para 3. complaining of secondary amenorrhea of 8 weeks’ duration. was found to have an 8 to 9 cm right adnexal mass, 5 months after the delivery of her third child. Pelvic examination at the time of her routine visit 6 weeks post partum had disclosed no pelvic abnormalities. Progesterone was administered to induce withdrawal bleeding and regression of the adnexal mass. Two weeks later the patient was still amenorrheic and the adnexal mass had not changed in G/e. An exploratory laparotomy was performed in .Iugust, 1966: a large, smooth. shinv mass. without torsion, involving the entire right ovary, was noted. A right salpingo-oophorectomy and incidental appendectomy were performed. The left ovary appeared entirely normal. Postoperative course was un-
M.D.
CA s E reported
massive
current literature on the subject was available. The rrnusual pathologic features of this case were not recogniTed until the publication of the case reports and rcvie\vs of’ the literature by Kalstone and associates’ and by Chervenak and associates.’ Among the 22 previously reported cases, the vast majority were in nulliparous patients without long-term follow-up; this case is unique in that the lesion arose 5 months after a third delivery and of’t’ered a IO-year l’oll~~-up with an opportunity fhr inspection of the conserved ovary.
0
1981
1. Appearance The C. V. Mosby
of the edematous Co.
The specimen was a 10 by 8 by -l..i cm. smooth-surfaced, cystlike structure which weighed 205 gm, with an attached 8 by 0.4 by 0.4 cm fallopian tube. The cut surface was gelatinous gray to yellow surrounded by a rim of dense gray-white tissue. A few cysts which measured 0.5 cm in average diameter were seen. The fallopian tube was unremarkable. Microscopically edematous ovarian stroma was seen: normal-appearing dense areas were seen at the periphery of the cortex and around a few dilated follicles (Fig. 1). The patient was essentially asymptomatic until 1973, when she began to complain of menometrorrhagia and dysmenor-
ovarian
stroma.
(~315.)
Volume
140
Number
3
Communications
in brief
347
twin
preg-
rhea. Curettage and intermittent cyclic progestins seemed to result in temporary improvement until 1976. The patient, then 35 years old, underwent total abdominal hysterectomy, which revealed adenomyosis and a cellular leiomyoma. The normal left adnexa were conserved. The postoperative course was uneventful. Six months after surgery there were no complaints referable to the conserved left ovary. It is important for both gynecologist and pathologist to be aware of this lesion in the differential diagnosis of ovarian lesions because an erroneous diagnosis may lead to unnecessary surgical procedures. The etiology of massive ovarian edema remains obscure. REFERENCES
C. E., Jaffe, R. B., and Abell, M. R.: Massive 1. Kalstone, edema of the ovary simulating fibroma, Obstet. Gynecol. 34:564, 1969. ’ 2. Chervenak. F. A.. Castadot. M.-l., Wiederman, I., and Sedlis, A.: ‘Massive ovarian edema: review of world literature and report of two cases, Obstet. Gynecol. Surv. 35:677, 1980.
Fig. 1. Monochorionic nancy.
diamniotic
placenta
from
Intrauterine amputation in one monozygotic twin associated with amniotic band: A case report PUSHPA
L.
KANCHERLA,
VASU
G.
UNTAWALE,
JUAN
B.
GABRIEL,
PREM
M.
M.D. M.D. JR.,
CHAUHAN,
M.D. M.D.
Departments of Pathology, Harlem Hospital Center, Columbia University, Colkge of Physicians and Surgeons, New York, New York
A RARE and interesting finding of intrauterine amputation of the right arm at the elbow in one of a pair of twins because of amniotic band is described. To the best of our knowledge, this is the first reported case of intrauterine amputation involving only one of a pair of twins.
Possible
etiologic
factors
are
discussed.
An l&year-old woman, gravida 4, para 2, was delivered of twins at 36 weeks of gestation. The patient had a history of pre-eclampsia and upper respiratory tract infections. There was no history of abdominal trauma during gestation, leaking of amniotic fluid, or hydramnios. The patient was not addicted to drugs and stated that she had never taken lysergic acid diethylamide. There was no family history of congenital abnormalities. The membranes were ruptured during labor and two male
Reprint requests: Prem M. Chauhan, Pathology, Harlem Hospital Center, York, New York 10037. 0002-9378/81/l
10347+02$00.20/0
M.D., Department 506 Lenox Ave.,
of New
0 1981 The C. V. Mosby Co.
Fig. 2. Placenta
showing
amniotic
band
(arrouli.
infants were delivered vaginally. Both infants were small for gestational age. The firstborn infant was normal. The second infant showed absence of the right arm below the elbow. No other malformations were present. No chromosomal abnormalities were observed in either infant. A 612.0 gm monochorionic-diamniotic placenta with membranes and two umbilical cords was delivered. The first umbilical cord had a velamentous attachment and was edematous. The second umbilical cord was attached centrally (Fig. 1). At the insertion of the second umbilical cord there was an opaque, 2.5 by 2.0 by 0.5 cm semilmlar valve, beneath which a pouch was noted, into which a probe could be introduced to a depth of 1.0 cm (Fig. 2). No portion of the missing extremity was found. Each umbilical cord showed two arteries and a vein. There was a free, patent, artery-to-artery communication between the two circulations. There was no microscopic evidence of infection in the placenta or amniotic membranes. Marked fibrosis of the amnion was present in the region of the amniotic flap The amnion was absent over the adjacent chorion. The chorion was covered by normal amnion in the placental portion corresponding to the normal twin. Although
there
the most probable
was no history
of trauma,
cause of deformity,
the latter
is
as suggested
by
Communications
dicate umbilical lemia would effects
June 1. 1981 Am. J. Obstet. Gynecol.
in brief
fetal
hemodynamic adaptation to partial chronic vein compression. leading to relative hypovoand oliguria in utero. Chronic fetal oliguria explain the uligohydramnios seen here. Furthet on amniotic fluid volume, such as prevention of
egress of lung fluid via the laryngeal outlet, could be anticipated from compression of the fetal neck. Swallowing of amniotic fluid might also be reduced, but to a lesser degree, since the anatomically deeper esophagus was relatively protected from the external constriction band of‘ the nuchal cord. REFERENCES
1. Bruce, S., James, L. S., Bowe, E., et al.: Umbilical cord complications as a cause of perinatal morbidity and mortality. J. Perinat. Med. 6:89, 1978. 2. Sadovsky, E.. Weinstein. D.. Aboulafia, Y., et al.: Decreased fetal movements associated with umbilical cord complications, Isr. .J. Med. Sci. 13:295, 1977.
Massive ovarian edema JEROME G.
ABRAMS,
H.
Departments Muhlenberg THE
M.D
SALALAR.
eventfill.
of Obstetrics Hospital,
and Gynecology and Patholoa, Plainjield, New Jersq
ovarian
here edema
Reprint requests: Dr. Obstetrics and Gynecology, New Jersey 0706 1.
represents encountered
10346+02$00.2010
an
example
3 years
of before
Jerome Abrams. Department of Muhlenberg Hospital, Plainfield,
Fig. 0002-9378/81/l
A 25-year-old white woman, gravida 3, para 3. complaining of secondary amenorrhea of 8 weeks’ duration. was found to have an 8 to 9 cm right adnexal mass, 5 months after the delivery of her third child. Pelvic examination at the time of her routine visit 6 weeks post partum had disclosed no pelvic abnormalities. Progesterone was administered to induce withdrawal bleeding and regression of the adnexal mass. Two weeks later the patient was still amenorrheic and the adnexal mass had not changed in G/e. An exploratory laparotomy was performed in .Iugust, 1966: a large, smooth. shinv mass. without torsion, involving the entire right ovary, was noted. A right salpingo-oophorectomy and incidental appendectomy were performed. The left ovary appeared entirely normal. Postoperative course was un-
M.D.
CA s E reported
massive
current literature on the subject was available. The rrnusual pathologic features of this case were not recogniTed until the publication of the case reports and rcvie\vs of’ the literature by Kalstone and associates’ and by Chervenak and associates.’ Among the 22 previously reported cases, the vast majority were in nulliparous patients without long-term follow-up; this case is unique in that the lesion arose 5 months after a third delivery and of’t’ered a IO-year l’oll~~-up with an opportunity fhr inspection of the conserved ovary.
0
1981
1. Appearance The C. V. Mosby
of the edematous Co.
The specimen was a 10 by 8 by -l..i cm. smooth-surfaced, cystlike structure which weighed 205 gm, with an attached 8 by 0.4 by 0.4 cm fallopian tube. The cut surface was gelatinous gray to yellow surrounded by a rim of dense gray-white tissue. A few cysts which measured 0.5 cm in average diameter were seen. The fallopian tube was unremarkable. Microscopically edematous ovarian stroma was seen: normal-appearing dense areas were seen at the periphery of the cortex and around a few dilated follicles (Fig. 1). The patient was essentially asymptomatic until 1973, when she began to complain of menometrorrhagia and dysmenor-
ovarian
stroma.
(~315.)
Volume
140
Number
3
Communications
in brief
347
twin
preg-
rhea. Curettage and intermittent cyclic progestins seemed to result in temporary improvement until 1976. The patient, then 35 years old, underwent total abdominal hysterectomy, which revealed adenomyosis and a cellular leiomyoma. The normal left adnexa were conserved. The postoperative course was uneventful. Six months after surgery there were no complaints referable to the conserved left ovary. It is important for both gynecologist and pathologist to be aware of this lesion in the differential diagnosis of ovarian lesions because an erroneous diagnosis may lead to unnecessary surgical procedures. The etiology of massive ovarian edema remains obscure. REFERENCES
C. E., Jaffe, R. B., and Abell, M. R.: Massive 1. Kalstone, edema of the ovary simulating fibroma, Obstet. Gynecol. 34:564, 1969. ’ 2. Chervenak. F. A.. Castadot. M.-l., Wiederman, I., and Sedlis, A.: ‘Massive ovarian edema: review of world literature and report of two cases, Obstet. Gynecol. Surv. 35:677, 1980.
Fig. 1. Monochorionic nancy.
diamniotic
placenta
from
Intrauterine amputation in one monozygotic twin associated with amniotic band: A case report PUSHPA
L.
KANCHERLA,
VASU
G.
UNTAWALE,
JUAN
B.
GABRIEL,
PREM
M.
M.D. M.D. JR.,
CHAUHAN,
M.D. M.D.
Departments of Pathology, Harlem Hospital Center, Columbia University, Colkge of Physicians and Surgeons, New York, New York
A RARE and interesting finding of intrauterine amputation of the right arm at the elbow in one of a pair of twins because of amniotic band is described. To the best of our knowledge, this is the first reported case of intrauterine amputation involving only one of a pair of twins.
Possible
etiologic
factors
are
discussed.
An l&year-old woman, gravida 4, para 2, was delivered of twins at 36 weeks of gestation. The patient had a history of pre-eclampsia and upper respiratory tract infections. There was no history of abdominal trauma during gestation, leaking of amniotic fluid, or hydramnios. The patient was not addicted to drugs and stated that she had never taken lysergic acid diethylamide. There was no family history of congenital abnormalities. The membranes were ruptured during labor and two male
Reprint requests: Prem M. Chauhan, Pathology, Harlem Hospital Center, York, New York 10037. 0002-9378/81/l
10347+02$00.20/0
M.D., Department 506 Lenox Ave.,
of New
0 1981 The C. V. Mosby Co.
Fig. 2. Placenta
showing
amniotic
band
(arrouli.
infants were delivered vaginally. Both infants were small for gestational age. The firstborn infant was normal. The second infant showed absence of the right arm below the elbow. No other malformations were present. No chromosomal abnormalities were observed in either infant. A 612.0 gm monochorionic-diamniotic placenta with membranes and two umbilical cords was delivered. The first umbilical cord had a velamentous attachment and was edematous. The second umbilical cord was attached centrally (Fig. 1). At the insertion of the second umbilical cord there was an opaque, 2.5 by 2.0 by 0.5 cm semilmlar valve, beneath which a pouch was noted, into which a probe could be introduced to a depth of 1.0 cm (Fig. 2). No portion of the missing extremity was found. Each umbilical cord showed two arteries and a vein. There was a free, patent, artery-to-artery communication between the two circulations. There was no microscopic evidence of infection in the placenta or amniotic membranes. Marked fibrosis of the amnion was present in the region of the amniotic flap The amnion was absent over the adjacent chorion. The chorion was covered by normal amnion in the placental portion corresponding to the normal twin. Although
there
the most probable
was no history
of trauma,
cause of deformity,
the latter
is
as suggested
by