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Non-surgical pneumoperitoneum following cervical smear test
240
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 131 (2007) 235–245
Table 1 Types of pigmentary demarcation lines (PDLs)
Non-surgical pneumoperitoneum following cervical smear test
A: lateral aspect of upper anterior portion of arms, across pectoral area B: posterior medial portion of lower limb C: vertical hypopigmentation line in pre and para sternal area D: posterior medial area of spine E: bilateral aspect of chest, marking from mid-third of clavicle to periareolar skin F: straight of curved convex line on the face
pigmentary change during pregnancy is the development of a mask-like facial hyperpigmentation known as melasma or chloasma. The degree of hyperpigmentation tends to be related to the skin type of the individual. Additionally, preexisting nevi frequently become darker during pregnancy. In most of the cases regression (or partial regression) of the hyperpigmentation occurs gradually following termination of pregnancy. The physiology of hyperpigmentation appears to be related to the increased production of estrogens and perhaps to increased levels of progesterone or melanocyte stimulating hormone. Hyperpigmentation lines on the buttocks and flexor aspects of the legs are uncommon and known as PDLs type 2. Compression by the enlarged uterus of peripheral nerves issuing at S1–S2 is proposed as a mechanism of these changes. In most of the published cases, as well as in this case, pigmentation resolved spontaneously few months after delivery [1–4].
References [1] James WD, Carter JM, Rodman OG. Pigmentary demarcation lines: a population survey. J Am Acad Dermatol 1987;16:584–90. [2] Ozawa H, Rokugo M, Aoyama H. Pigmentary demarcation lines of pregnancy with erythema. Dermatology 1993;187:134–6. [3] Gupta LK, Kuldeep CM, Mittal A, et al. Pigmentary demarcation lines in pregnancy. Indian J Dermatol Venereol Leprol 2005;71:292–3. [4] Ruiz-Villaverde R, Blasco-Melguizo J, Naranjo-Sintes R. Pigmentary demarcation lines in a pregnant Caucasian woman. Int J Dermatol 2004;43:911–2.
B. Amichai* Dermato-Gynecological Unit, Huzot Clinic of Clalit Health Services, Ashkelon, Israel M.H. Grunwald Soroka University Medical Center, Beer-Sheva, Israel *Corresponding author. Tel.: +972 52 2892969; fax: +972 8 6770716 E-mail address: [email protected], [email protected] 28 October 2005 doi:10.1016/j.ejogrb.2006.04.030
Dear Editor, A 42-year-old nulliparous woman presented to the emergency department complaining of 2-week history of dyspepsia. Physical examination revealed pyrexia (38 8C), mild epigastric peritonism and abdominal distention with normal bowel sounds. The erect Chest X-ray showed large amounts of free air under both hemi-diaphragms. Laboratory investigation revealed mild leucocytosis (13.6 109 L 1, upper limit: 13.0 109 L 1). Urine microscopy was negative. The patient had an unremarkable medical history and had never undergone any surgical or endoscopic interventions. She was not sexually active during the last 3 months. The decision was made to proceed to exploratory laparotomy. Laparotomy did not reveal free fluid, visceral perforation or other intra-abdominal pathology. Peritoneal lavage was performed, the patient made an uneventful recovery and was discharged home in 4 days. On further questioning a week later, the patient admitted that 2 days prior to the onset of pain she had undergone a cervical Pap-test by a practice-nurse. The Pap-test was prolonged (20 min) as the nurse had difficulties in locating the cervix, and tried several techniques including placing the patient’s fists behind the pelvis, as well as the left lateral position. Non-surgical, idiopathic or primary pneumoperitoneum (NSP) is defined as the presence of free air in the peritoneal cavity, for which no surgical cause can be identified [1]. Most cases of NSP occur as a procedural complication or as a complication of medical intervention. The most common abdominal causes of NSP are retained postoperative air, peritoneal dialysis catheter placement, pneumatosis cystoides intestinalis and after gastrointestinal endoscopic procedures [2]. The most common thoracic causes include mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax [2]. Gynaecological causes of NSP although rare in comparison with other etiologies, occur when air passes upward through the genital tract to the peritoneum via the uterus and fallopian tubes. The introduction of air through the genital canal can occur either by pressure applied externally or by vacuum created by rapid positional changes of the lower torso [2]. Following physiological studies, Lozman and Newman showed a positive intra-pelvic pressure in the erect and a negative in the knee-elbow position. In the lateral/pelvic tilt position (which was tried in our case) it is thought that the intra-abdominal contents move cephalad, creating a negative intrapelvic pressure, which results in a vacuum phenomenon [3]. Examples of gynaecological causes of NSP include post-partum knee-elbow exercises, vaginal douching, Jacuzzi usage, water-skiing, tubal insufflation in hysterosalpingogram, pelvic inflammatory disease, and coitus [1]. Some reports imply that genital anatomical
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 131 (2007) 235–245
abnormalities can predispose to gynaecologic causes of NSP, although other reports have not found such an association [3]. Management of NSP should be conservative. Mularski et al. conducted a medline review from 1970 to 1999 and identified 196 reported cases of NSP of which 45 underwent surgical exploration without evidence of perforated viscus [2]. Most reported cases of NSP have either historical or clinical clues that could suggest a non-surgical approach. In most reported cases of NSP, abdominal pain and distention are not significant, while peritoneal signs, fever and leucocytosis are absent. A detailed clinical history with emphasis on non-surgical causes of pneumoperitoneum is mandatory and will guide the clinician towards the best treatment option. In our case, we proceeded to a surgical approach as there was low grade pyrexia, mild leucocytosis, and localised peritonism, which are unusual in patients with NSP. The only possible cause of NSP obtained from the patient’s history, was a rather prolonged smear test due to inability to visualise the cervix, during which various manoeuvres were tried including the left lateral and pelvic tilt position. This probably resulted in a negative intrapelvic pressure leading to introduction of air into the peritoneal cavity. In summary we report a case of a Pap-test associated NSP which, to our knowledge, has never been described in the literature. Clinicians should be aware that gas under the diaphragm does not always mean perforated abdominal viscus and maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum, as these cases should be managed conservatively. An appreciation of the condition and its likely etiological factors should improve awareness and possibly reduce the imperative to perform emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.
References [1] Mularski RA, Ciccolo ML, Rappaport WD. Nonsurgical causes of pneumoperitoneum. West J Med 1999;170:41–6. [2] Mularski RA, Sippel JM, Osborn ML. Pneumoperitoneum. A review of nonsurgical causes. Crit Care Med 2000;28:2638–44. [3] Lozman H, Newman AJ. Spontaneous pneumoperitoneum occurring during post-partum exercises in the knee-chest position. Am J Obstet Gynaecol 1956;72:903.
Paraskevi A. Vlachou* Mansoor Aslam Departments of Radiology, Pilgrim Hospital, Boston PE21 9QS, UK Antonios Ntatsios George K. Anagnostopoulos Department of Medicine, Queen’s Medical Centre, Nottingham NG7 2UH, UK
241
Paul Murphy General Surgery, Pilgrim Hospital, Boston PE21 9QS, UK *Correspondence to: Department of Radiology, Pilgrim Hospital, Sibsey Road, Boston, Lincolnshire PE21 9QS, UK. Tel.: +44 1205 364801 E-mail address: [email protected] (P.A. Vlachou) 7 January 2006 doi:10.1016/j.ejogrb.2006.04.025
Hemolysis, elevated liver enzymes and low platelets during pregnancy due to Vitamin B12 and folate deficiencies Dear Editor, We recently treated three pregnant women who were referred because of a suspected HELLP syndrome, in whom laboratory findings were abnormal due to a deficiency of Vitamin B12 or folic acid. These deficiencies generally have not been included in the differential diagnosis of a HELLP syndrome. We present one case as example of misinterpretation of laboratory results. A 34-year-old gravida 7, para 2, was treated with methyldopa because of chronic hypertension. At 36 weeks gestation, her blood pressure raised until 150/110 mmHg. Headache, abdominal pain, edema or uterus contractions were absent. Laboratory findings showed a hemoglobin (Hb) of 4.8 mmol/L, MCV 94 fl, reticulocytes 0.3% (normal 0.7– 2.4%), LDH 5223 U/L (normal <450), platelet count 146 109/L (nadir 92 109/L), urine albumin negative, ASAT 117 U/L (normal <31), uric acid 0.38 mmol/L. Based on these laboratory results, it was concluded that she suffered from a HELLP syndrome and she was referred to the hospital. The next day, induction of labour led to a vaginal delivery of a healthy male infant of 2975 g. Hb postpartum was 4.1 mmol/L, for which she received three packed cells. Blood pressure postpartum was 130/80 mmHg. However, LDH, ASAT and ALAT values remained elevated. Hemolysis due to Vitamin B12 deficiency was suspected. Additional history taking revealed that she only had eaten some white bread and no fruit, vegetables, milk, potatoes or meat during pregnancy. Vitamin B12 was 81 (normal value 120–640) pmol/L, folic acid 6.4 nmol/L (8–28). Suppletion of Vitamin B12, folic acid and iron resulted in normalization of hemoglobin and liver enzymes. Folate is essential for hematopoiesis and cell growth and division. Deficiency of folate is the most common cause of macrocytosis in pregnancy [1], but may not be recognized due to a coexisting iron deficiency. Other causes of macrocytosis are hypothyroidism, Vitamin B12 deficiency,
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 131 (2007) 235–245
Table 1 Types of pigmentary demarcation lines (PDLs)
Non-surgical pneumoperitoneum following cervical smear test
A: lateral aspect of upper anterior portion of arms, across pectoral area B: posterior medial portion of lower limb C: vertical hypopigmentation line in pre and para sternal area D: posterior medial area of spine E: bilateral aspect of chest, marking from mid-third of clavicle to periareolar skin F: straight of curved convex line on the face
pigmentary change during pregnancy is the development of a mask-like facial hyperpigmentation known as melasma or chloasma. The degree of hyperpigmentation tends to be related to the skin type of the individual. Additionally, preexisting nevi frequently become darker during pregnancy. In most of the cases regression (or partial regression) of the hyperpigmentation occurs gradually following termination of pregnancy. The physiology of hyperpigmentation appears to be related to the increased production of estrogens and perhaps to increased levels of progesterone or melanocyte stimulating hormone. Hyperpigmentation lines on the buttocks and flexor aspects of the legs are uncommon and known as PDLs type 2. Compression by the enlarged uterus of peripheral nerves issuing at S1–S2 is proposed as a mechanism of these changes. In most of the published cases, as well as in this case, pigmentation resolved spontaneously few months after delivery [1–4].
References [1] James WD, Carter JM, Rodman OG. Pigmentary demarcation lines: a population survey. J Am Acad Dermatol 1987;16:584–90. [2] Ozawa H, Rokugo M, Aoyama H. Pigmentary demarcation lines of pregnancy with erythema. Dermatology 1993;187:134–6. [3] Gupta LK, Kuldeep CM, Mittal A, et al. Pigmentary demarcation lines in pregnancy. Indian J Dermatol Venereol Leprol 2005;71:292–3. [4] Ruiz-Villaverde R, Blasco-Melguizo J, Naranjo-Sintes R. Pigmentary demarcation lines in a pregnant Caucasian woman. Int J Dermatol 2004;43:911–2.
B. Amichai* Dermato-Gynecological Unit, Huzot Clinic of Clalit Health Services, Ashkelon, Israel M.H. Grunwald Soroka University Medical Center, Beer-Sheva, Israel *Corresponding author. Tel.: +972 52 2892969; fax: +972 8 6770716 E-mail address: [email protected], [email protected] 28 October 2005 doi:10.1016/j.ejogrb.2006.04.030
Dear Editor, A 42-year-old nulliparous woman presented to the emergency department complaining of 2-week history of dyspepsia. Physical examination revealed pyrexia (38 8C), mild epigastric peritonism and abdominal distention with normal bowel sounds. The erect Chest X-ray showed large amounts of free air under both hemi-diaphragms. Laboratory investigation revealed mild leucocytosis (13.6 109 L 1, upper limit: 13.0 109 L 1). Urine microscopy was negative. The patient had an unremarkable medical history and had never undergone any surgical or endoscopic interventions. She was not sexually active during the last 3 months. The decision was made to proceed to exploratory laparotomy. Laparotomy did not reveal free fluid, visceral perforation or other intra-abdominal pathology. Peritoneal lavage was performed, the patient made an uneventful recovery and was discharged home in 4 days. On further questioning a week later, the patient admitted that 2 days prior to the onset of pain she had undergone a cervical Pap-test by a practice-nurse. The Pap-test was prolonged (20 min) as the nurse had difficulties in locating the cervix, and tried several techniques including placing the patient’s fists behind the pelvis, as well as the left lateral position. Non-surgical, idiopathic or primary pneumoperitoneum (NSP) is defined as the presence of free air in the peritoneal cavity, for which no surgical cause can be identified [1]. Most cases of NSP occur as a procedural complication or as a complication of medical intervention. The most common abdominal causes of NSP are retained postoperative air, peritoneal dialysis catheter placement, pneumatosis cystoides intestinalis and after gastrointestinal endoscopic procedures [2]. The most common thoracic causes include mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax [2]. Gynaecological causes of NSP although rare in comparison with other etiologies, occur when air passes upward through the genital tract to the peritoneum via the uterus and fallopian tubes. The introduction of air through the genital canal can occur either by pressure applied externally or by vacuum created by rapid positional changes of the lower torso [2]. Following physiological studies, Lozman and Newman showed a positive intra-pelvic pressure in the erect and a negative in the knee-elbow position. In the lateral/pelvic tilt position (which was tried in our case) it is thought that the intra-abdominal contents move cephalad, creating a negative intrapelvic pressure, which results in a vacuum phenomenon [3]. Examples of gynaecological causes of NSP include post-partum knee-elbow exercises, vaginal douching, Jacuzzi usage, water-skiing, tubal insufflation in hysterosalpingogram, pelvic inflammatory disease, and coitus [1]. Some reports imply that genital anatomical
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 131 (2007) 235–245
abnormalities can predispose to gynaecologic causes of NSP, although other reports have not found such an association [3]. Management of NSP should be conservative. Mularski et al. conducted a medline review from 1970 to 1999 and identified 196 reported cases of NSP of which 45 underwent surgical exploration without evidence of perforated viscus [2]. Most reported cases of NSP have either historical or clinical clues that could suggest a non-surgical approach. In most reported cases of NSP, abdominal pain and distention are not significant, while peritoneal signs, fever and leucocytosis are absent. A detailed clinical history with emphasis on non-surgical causes of pneumoperitoneum is mandatory and will guide the clinician towards the best treatment option. In our case, we proceeded to a surgical approach as there was low grade pyrexia, mild leucocytosis, and localised peritonism, which are unusual in patients with NSP. The only possible cause of NSP obtained from the patient’s history, was a rather prolonged smear test due to inability to visualise the cervix, during which various manoeuvres were tried including the left lateral and pelvic tilt position. This probably resulted in a negative intrapelvic pressure leading to introduction of air into the peritoneal cavity. In summary we report a case of a Pap-test associated NSP which, to our knowledge, has never been described in the literature. Clinicians should be aware that gas under the diaphragm does not always mean perforated abdominal viscus and maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum, as these cases should be managed conservatively. An appreciation of the condition and its likely etiological factors should improve awareness and possibly reduce the imperative to perform emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.
References [1] Mularski RA, Ciccolo ML, Rappaport WD. Nonsurgical causes of pneumoperitoneum. West J Med 1999;170:41–6. [2] Mularski RA, Sippel JM, Osborn ML. Pneumoperitoneum. A review of nonsurgical causes. Crit Care Med 2000;28:2638–44. [3] Lozman H, Newman AJ. Spontaneous pneumoperitoneum occurring during post-partum exercises in the knee-chest position. Am J Obstet Gynaecol 1956;72:903.
Paraskevi A. Vlachou* Mansoor Aslam Departments of Radiology, Pilgrim Hospital, Boston PE21 9QS, UK Antonios Ntatsios George K. Anagnostopoulos Department of Medicine, Queen’s Medical Centre, Nottingham NG7 2UH, UK
241
Paul Murphy General Surgery, Pilgrim Hospital, Boston PE21 9QS, UK *Correspondence to: Department of Radiology, Pilgrim Hospital, Sibsey Road, Boston, Lincolnshire PE21 9QS, UK. Tel.: +44 1205 364801 E-mail address: [email protected] (P.A. Vlachou) 7 January 2006 doi:10.1016/j.ejogrb.2006.04.025
Hemolysis, elevated liver enzymes and low platelets during pregnancy due to Vitamin B12 and folate deficiencies Dear Editor, We recently treated three pregnant women who were referred because of a suspected HELLP syndrome, in whom laboratory findings were abnormal due to a deficiency of Vitamin B12 or folic acid. These deficiencies generally have not been included in the differential diagnosis of a HELLP syndrome. We present one case as example of misinterpretation of laboratory results. A 34-year-old gravida 7, para 2, was treated with methyldopa because of chronic hypertension. At 36 weeks gestation, her blood pressure raised until 150/110 mmHg. Headache, abdominal pain, edema or uterus contractions were absent. Laboratory findings showed a hemoglobin (Hb) of 4.8 mmol/L, MCV 94 fl, reticulocytes 0.3% (normal 0.7– 2.4%), LDH 5223 U/L (normal <450), platelet count 146 109/L (nadir 92 109/L), urine albumin negative, ASAT 117 U/L (normal <31), uric acid 0.38 mmol/L. Based on these laboratory results, it was concluded that she suffered from a HELLP syndrome and she was referred to the hospital. The next day, induction of labour led to a vaginal delivery of a healthy male infant of 2975 g. Hb postpartum was 4.1 mmol/L, for which she received three packed cells. Blood pressure postpartum was 130/80 mmHg. However, LDH, ASAT and ALAT values remained elevated. Hemolysis due to Vitamin B12 deficiency was suspected. Additional history taking revealed that she only had eaten some white bread and no fruit, vegetables, milk, potatoes or meat during pregnancy. Vitamin B12 was 81 (normal value 120–640) pmol/L, folic acid 6.4 nmol/L (8–28). Suppletion of Vitamin B12, folic acid and iron resulted in normalization of hemoglobin and liver enzymes. Folate is essential for hematopoiesis and cell growth and division. Deficiency of folate is the most common cause of macrocytosis in pregnancy [1], but may not be recognized due to a coexisting iron deficiency. Other causes of macrocytosis are hypothyroidism, Vitamin B12 deficiency,