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Ovarian pregnancy with an intrauterine contraceptive device in situ: A case report
COMMUNICATIONS IN BRIEF
Ovarian pregnancy with intrauterine contraceptive in situ: A case report ANTHONY
T.
S. ‘THEODORE
BOZZA,
M.D.
HORWITZ,
M.D.
Departments of Obstetrics and Gynecology the North Shore Hospital and the Cornell University Medical College, Manhasset, Long Island, New York.
I N
R E c E N T
publications,
The patient’s past history revealed “adrenal hyperplasia” 5 years before, for which she had received 10 mg. of prednisone daily. A Dalkon Shield had been inserted 1% years prior to admission and was well tolerated. On physical examination, the patient was acutely ill, pale, with a blood pressure of 100/80, a pulse of 84, respirations of 20, and a temperature of 37.6” C. The abdomen revealed minimal bowel sounds, mild rebound, and guarding in both lower quadrants. The pelvic examination was difficult, because of the exquisite tenderness on cervical motion. Culdocentesis revealed dark blood, which failed to clot. Laboratory values revealed a hemoglobin of 10.7, hematocrit of 32, white blood cell count of 12,400, and a positive urinary chorionic gonadotropin. The admitting diagnosis was one of hemoperitoneum, secondary to a ruptured corpus luteum cyst or ectopic pregnancy. Laparoscopy, followed by laparotomy, revealed a hemoperitoneum with 800 C.C. of free blood. Both ovaries were somewhat cystic and a bleeding apparent corpus luteum cyst was noted on the right ovary. Both tubes appeared to be normal, intact, and uninvolved. A bilateral ovarian cystectomy was performed. The patient was transfused with 3 U. of blood, and the postoperative course was uneventful. On the fourth postoperative day, the Dalkon Shield was removed, and she was discharged on the seventh postoperative day. When examined 4 weeks following operation, the pelvic examination was normal, and a urinary chorionic gonadotropin test at that time was negative. The pathology report revealed a right ovarian cyst, containing chorionic villi, decidua, and blood clots. The left ovarian cyst was consistent with a corpus luteum. The final pathologic diagnosis was: ( 1) right ovary-products of pregnancy, and (2) left ovary-corpus luteum cyst.
an device
it
has been
of
shown
that intrauterine contraceptive device (IUCD) wearers have no protection against ectopic pregnancies, and the rate of ovarian pregnancy is not a1terecl.r In reviewing the literature, a few interesting points emerge : 1. In all the cases we have found in a search of recent reports of ovarian pregnancy with an IUCD in situ, it is the right side which is effected.11 * 2. The majority of cases reported occur with the Lippes Loop* in place, and, to our knowledge, none has been reported with a Dalkon Shield.? in place. 3. The initial diagnosis is usually a bleeding corpus luteum cyst, the patient presenting with abnormal bleeding and lower abdominal pain. S. C. is a 24-year-old white woman, gravida 1, Para O-O-I-O, last menstrual period July 6, 1972, who was admitted to North Shore Hospital through the Emergency Room, on July 20, 1972, with the chief complaint of severe suprapubic pain, which began suddenly 6 hours prior to admission. “Normal” menses were 2 weeks before, but she had noted minimal staining 3 days prior to admission. She had been aware of mild dyspareunia. Reprint requests: Dr. Anthony Obstetrics and Gynecology, North Long Idand, New York 11030. “Ortho tA.
H.
Pharm.
Corp.,
Robins
Co.,
Raritan, Inc.,
This case clearly fulfills Spiegelberg’s criteria for the diagnosis of an ovarian pregnancy. The tube on the affected side was apparently normal; the sac occupied the normal position on the ovary, and the specimen contained not only chorionic villi but also decidua and a corpus luteum. It represents yet another in a series of recent reports of ectopic pregnancy in association with an IUCD. It is necessary for the gynecologist to be alert to the possibility of an ectopic pregnancy in spite of the presence of an IUCD.
T. Bozza, Department of Shore Hospital, Manhasset, New
Richmond,
Jersey. Virginia.
285
286
In
Communications
in brief
a recent
of
report
30,000
women
wearing
are not only seldom recognized or suspected but are sometimes mistaken for the more common diseases of the gastrointestinal tract.“, 8-r” To the gynecologist these tumors naturally have evoked little or no interest because they are primarily the concern of surgeons, Even so, a survey of the literature reveals that these tumors of the small bowel can have features closely resembling those of ovarian cancer.?, 7~ 8, I11 Unless gynecologists are aware of this fact, such
HJCD’s, it was clearly demonstrated that, while the wearing of an IUCD reduced uterine implantation by 99.5 per cent, the incidence of expected ovarian pregnancy was not affected at all.’ Pregnancy, particularly ovarian, is undoubtedly because of the fact that the devices do function more effectively in preventing uterine pregnancy than ectopic implantation. The potential hazard of an undiagnosed ovarian pregnancy has prompted us to report what we believe to be the first case of ovarian pregnancy have not the right we hope dominance
associated with the Dalkon Shield. been able to explain the dominance ovary in the available case reports, that as more cases are reported will diminish or be clarified.
We of but this
REFERENCE5
1. Lehfelt, H., Tietze, C., and Gorstein, F.: AM. J. OBSTET. GYNECOL. 108: 1005, 1970. 2. Levin, S., Caspi, E., and Hirsh, H.: AM. J. OBSTET. GYNECOL. 113: 843, 1972.
The significance of primary malignant tumors of the small bowel in gynecologic practice: A report of two cases W.
F.
CHAN,
M.B.B.S.(MALAYA),
F.R.C.S.(EDIN.), K.
M.R.C.O.G.
SOMASUNDARAM,
M.B.B.S. F.R.C.S.(ENG.),
(CEYLON),
F.R.C.S.(EDIN.) P. W.
KOHNEN,
Department University Malaysia
M.D.,
PH.D.
of Obstetrics and Gynaecology, of Malaya, Kuala Lumpur,
PRIMARY LEIOMYOSARCOMA and lymphosarcoma of the small intestine are rare tumors of the gastrointestinal tract, accounting for less than 4 per cent17 6, 8% Q. 11 of all gastrointestinal malignancies. Because of their rarity and the lack of distinctive clinical features, these tumors Reprint Obstetrics Lwnpur,
requests:
Dr.
and Gy~~ecology, Malaysia.
W.
F.
University
Chan, of
Department Malaya,
of Kuala
lesions are likely to be missed. It is with this emphasis in mind that we wish to report 2 cases of primary malignant tumors of the small intestine ovarian
erroneously tumors.
diagnosed
as
malignant
Patient No. 1, a 32-year-old unmarried woman, was admitted to the University Hospital, Kuala Lumpur, on May 29, 1970, with a history of lower abdominal pain and abdominal swelling for 2 months. Pain was dull in nature and was not related to meals, There was no vomiting, hematemesis, diarrhea, or melenic stools. Appetite was good. She had lost several pounds in the 2 months prior to admission, Micturition and bowel habits were normal. No change in menstruation was recorded. On physical examination, there was marked pallor. Abdominal examination revealed a firm, smooth, round, tender mass about the size of a 20 week pregnancy in the lower abdomen. It was limited in mobility. Its lower pole could be felt easily above the symphysis pubis, The liver, spleen, and kidneys were not palpable. On rectal examination, the mass was felt with difficulty to the right of the rectum. A provisional diagnosis of malignant ovarian tumor was made. The hemoglobin was 6.3 Gm. per cent. The chest x-ray and the intravenous pyelogram were normal. The patient was transfused with 2 U. of blood on June 1, 1970. At laparotomy on June 4, 1970, a large, friable, fleshy, metastatic lesion measuring 15 cm. in diameter was found filling the lower abdomen and involving the right parietal peritoneum and the omentum. The lower pole of this mass had infiltrated the anterior leaf of the right broad ligament. The uterus, ovaries, and tubes were normal. There was no ascites. The liver, spleen, and kidneys were normal. The para-aortic glands were not palpable. On exploration of the upper abdomen, a polypoid hemorrhagic growth 6 cm. in diameter was found attached to the antimesenteric border of the upper jejunum. The operative diagnosis was primary leiomyosarcoma of the jejunum with metastases in the lower abdomen. A primary resection of the jejunal tumor with end-to-end anastomosis was done. Except for a small area of residual tumor which had infiltrated the right broad ligament, the entire metastatic growth was removed with no difficulty. The postoperative period was uneventful. The patient was advised to have post-
Ovarian pregnancy with intrauterine contraceptive in situ: A case report ANTHONY
T.
S. ‘THEODORE
BOZZA,
M.D.
HORWITZ,
M.D.
Departments of Obstetrics and Gynecology the North Shore Hospital and the Cornell University Medical College, Manhasset, Long Island, New York.
I N
R E c E N T
publications,
The patient’s past history revealed “adrenal hyperplasia” 5 years before, for which she had received 10 mg. of prednisone daily. A Dalkon Shield had been inserted 1% years prior to admission and was well tolerated. On physical examination, the patient was acutely ill, pale, with a blood pressure of 100/80, a pulse of 84, respirations of 20, and a temperature of 37.6” C. The abdomen revealed minimal bowel sounds, mild rebound, and guarding in both lower quadrants. The pelvic examination was difficult, because of the exquisite tenderness on cervical motion. Culdocentesis revealed dark blood, which failed to clot. Laboratory values revealed a hemoglobin of 10.7, hematocrit of 32, white blood cell count of 12,400, and a positive urinary chorionic gonadotropin. The admitting diagnosis was one of hemoperitoneum, secondary to a ruptured corpus luteum cyst or ectopic pregnancy. Laparoscopy, followed by laparotomy, revealed a hemoperitoneum with 800 C.C. of free blood. Both ovaries were somewhat cystic and a bleeding apparent corpus luteum cyst was noted on the right ovary. Both tubes appeared to be normal, intact, and uninvolved. A bilateral ovarian cystectomy was performed. The patient was transfused with 3 U. of blood, and the postoperative course was uneventful. On the fourth postoperative day, the Dalkon Shield was removed, and she was discharged on the seventh postoperative day. When examined 4 weeks following operation, the pelvic examination was normal, and a urinary chorionic gonadotropin test at that time was negative. The pathology report revealed a right ovarian cyst, containing chorionic villi, decidua, and blood clots. The left ovarian cyst was consistent with a corpus luteum. The final pathologic diagnosis was: ( 1) right ovary-products of pregnancy, and (2) left ovary-corpus luteum cyst.
an device
it
has been
of
shown
that intrauterine contraceptive device (IUCD) wearers have no protection against ectopic pregnancies, and the rate of ovarian pregnancy is not a1terecl.r In reviewing the literature, a few interesting points emerge : 1. In all the cases we have found in a search of recent reports of ovarian pregnancy with an IUCD in situ, it is the right side which is effected.11 * 2. The majority of cases reported occur with the Lippes Loop* in place, and, to our knowledge, none has been reported with a Dalkon Shield.? in place. 3. The initial diagnosis is usually a bleeding corpus luteum cyst, the patient presenting with abnormal bleeding and lower abdominal pain. S. C. is a 24-year-old white woman, gravida 1, Para O-O-I-O, last menstrual period July 6, 1972, who was admitted to North Shore Hospital through the Emergency Room, on July 20, 1972, with the chief complaint of severe suprapubic pain, which began suddenly 6 hours prior to admission. “Normal” menses were 2 weeks before, but she had noted minimal staining 3 days prior to admission. She had been aware of mild dyspareunia. Reprint requests: Dr. Anthony Obstetrics and Gynecology, North Long Idand, New York 11030. “Ortho tA.
H.
Pharm.
Corp.,
Robins
Co.,
Raritan, Inc.,
This case clearly fulfills Spiegelberg’s criteria for the diagnosis of an ovarian pregnancy. The tube on the affected side was apparently normal; the sac occupied the normal position on the ovary, and the specimen contained not only chorionic villi but also decidua and a corpus luteum. It represents yet another in a series of recent reports of ectopic pregnancy in association with an IUCD. It is necessary for the gynecologist to be alert to the possibility of an ectopic pregnancy in spite of the presence of an IUCD.
T. Bozza, Department of Shore Hospital, Manhasset, New
Richmond,
Jersey. Virginia.
285
286
In
Communications
in brief
a recent
of
report
30,000
women
wearing
are not only seldom recognized or suspected but are sometimes mistaken for the more common diseases of the gastrointestinal tract.“, 8-r” To the gynecologist these tumors naturally have evoked little or no interest because they are primarily the concern of surgeons, Even so, a survey of the literature reveals that these tumors of the small bowel can have features closely resembling those of ovarian cancer.?, 7~ 8, I11 Unless gynecologists are aware of this fact, such
HJCD’s, it was clearly demonstrated that, while the wearing of an IUCD reduced uterine implantation by 99.5 per cent, the incidence of expected ovarian pregnancy was not affected at all.’ Pregnancy, particularly ovarian, is undoubtedly because of the fact that the devices do function more effectively in preventing uterine pregnancy than ectopic implantation. The potential hazard of an undiagnosed ovarian pregnancy has prompted us to report what we believe to be the first case of ovarian pregnancy have not the right we hope dominance
associated with the Dalkon Shield. been able to explain the dominance ovary in the available case reports, that as more cases are reported will diminish or be clarified.
We of but this
REFERENCE5
1. Lehfelt, H., Tietze, C., and Gorstein, F.: AM. J. OBSTET. GYNECOL. 108: 1005, 1970. 2. Levin, S., Caspi, E., and Hirsh, H.: AM. J. OBSTET. GYNECOL. 113: 843, 1972.
The significance of primary malignant tumors of the small bowel in gynecologic practice: A report of two cases W.
F.
CHAN,
M.B.B.S.(MALAYA),
F.R.C.S.(EDIN.), K.
M.R.C.O.G.
SOMASUNDARAM,
M.B.B.S. F.R.C.S.(ENG.),
(CEYLON),
F.R.C.S.(EDIN.) P. W.
KOHNEN,
Department University Malaysia
M.D.,
PH.D.
of Obstetrics and Gynaecology, of Malaya, Kuala Lumpur,
PRIMARY LEIOMYOSARCOMA and lymphosarcoma of the small intestine are rare tumors of the gastrointestinal tract, accounting for less than 4 per cent17 6, 8% Q. 11 of all gastrointestinal malignancies. Because of their rarity and the lack of distinctive clinical features, these tumors Reprint Obstetrics Lwnpur,
requests:
Dr.
and Gy~~ecology, Malaysia.
W.
F.
University
Chan, of
Department Malaya,
of Kuala
lesions are likely to be missed. It is with this emphasis in mind that we wish to report 2 cases of primary malignant tumors of the small intestine ovarian
erroneously tumors.
diagnosed
as
malignant
Patient No. 1, a 32-year-old unmarried woman, was admitted to the University Hospital, Kuala Lumpur, on May 29, 1970, with a history of lower abdominal pain and abdominal swelling for 2 months. Pain was dull in nature and was not related to meals, There was no vomiting, hematemesis, diarrhea, or melenic stools. Appetite was good. She had lost several pounds in the 2 months prior to admission, Micturition and bowel habits were normal. No change in menstruation was recorded. On physical examination, there was marked pallor. Abdominal examination revealed a firm, smooth, round, tender mass about the size of a 20 week pregnancy in the lower abdomen. It was limited in mobility. Its lower pole could be felt easily above the symphysis pubis, The liver, spleen, and kidneys were not palpable. On rectal examination, the mass was felt with difficulty to the right of the rectum. A provisional diagnosis of malignant ovarian tumor was made. The hemoglobin was 6.3 Gm. per cent. The chest x-ray and the intravenous pyelogram were normal. The patient was transfused with 2 U. of blood on June 1, 1970. At laparotomy on June 4, 1970, a large, friable, fleshy, metastatic lesion measuring 15 cm. in diameter was found filling the lower abdomen and involving the right parietal peritoneum and the omentum. The lower pole of this mass had infiltrated the anterior leaf of the right broad ligament. The uterus, ovaries, and tubes were normal. There was no ascites. The liver, spleen, and kidneys were normal. The para-aortic glands were not palpable. On exploration of the upper abdomen, a polypoid hemorrhagic growth 6 cm. in diameter was found attached to the antimesenteric border of the upper jejunum. The operative diagnosis was primary leiomyosarcoma of the jejunum with metastases in the lower abdomen. A primary resection of the jejunal tumor with end-to-end anastomosis was done. Except for a small area of residual tumor which had infiltrated the right broad ligament, the entire metastatic growth was removed with no difficulty. The postoperative period was uneventful. The patient was advised to have post-