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Ovarian pregnancy with in situ IUCD: Report of 2 cases
672
Communications
October. 15, 19x
in brief
Amer.
change found at the initial laparotomy in Case 2. Ideally, drainage of the appropriate cervix should have been sufficient. However, in Case 1 the abnormality was not recognized until laparotomy, when attempts were unsuccessful, and in Case 2 the pathology was not even appreciated at the first laparotomy. Successful treatment was achieved by excision of the infected hemiuterus in both. REFERENCES
1. 2. 3. 4.
5.
Merckel, G. C., Sucoff, M. C., and Sender, B.: AMER. J. OBSTET. GYNEC. 80: 70, 1960. Sampson, J. A.: Trans. Amer. Gynec. Sot. 52: 171, 1927. Scott, R. B., and Te Linde, R. W.: AMER. J. OBSTET. GYNEC. 60: 1147, 1950. Scott, R. B., Te Linde, R. W., and Wharton, L. R.: AMER. J. OBSTET. GYNEC. 66: 1082, 1953. Jeffcoate, T. N. A.: Principles of Gynaecology, London, 1962, Butterworth & Company, Ltd., p. 163.
Ovarian pregnancy with IUCD: Report of 2 cases ANTHONY ROBERT J.
VICTOR
PANE, SABATALLE, REYNIAK,
J. Obstet.
Gyncc.
Case 1. Miss C. U. (No. 14-42-30-FFAH), a 23-year-old primigravida, with a last menstrual period of Aug. 8, 1967, was admitted on Aug. 27, 1967, with the chief complaint of severe right lower quadrant pain. Nine days prior to admission, she had consulted her physician because of vaginal staining of 10 days’ duration. At that time, a right adnexal mass, approximately 5 X 5 cm. in size was palpated. An immunologic pregnancy test taken was negative. Physical examination revealed a moderately distressed female: blood pressure 100/40, pulse 100. There was diffuse lower abdominal tenderness with marked rebound tenderness in the right lower quadrant and diminished bowel sounds. The cervix was firm, noncyanotic, and moderately tender on motion. The tails of a Lippes loop inserted by her private doctor on April 9, 1967, protruded through the external OS. The uterus was normal size and freely mobile and the right adnexa suggested an ill-defined mass. Examination under anesthesia confirmed a right adnexal mass and culdocentesis produced 10 C.C. of unclotted blood. Upon exploration of the abdomen, approximately 1,000 C.C. of free blood in the peritoneal cavity was found which appeared to have come from a ruptured hemorrhagic cyst of the right ovary. The uterus, both tubes, and left ovary were grossly normal. A right ovarian cystectomy was performed.
in situ
M.D. M.D. M.D.
New York Medical College-Metropolitan Hospital Center, New York, New York E c T o P I c pregnancies with intrauterine devices in place are not uncommon occurrences. Recent statistics from the Population Council show 45 ectopic pregnancies out of 1,046 total pregnancies with diagnosed “in situ” intrauterine devices of all kinds, an estimate of approximately 1:23 pregnancies.l The incidence, moreover, of ectopic “ovarian” pregnancy is smaller (about 1: 25,000 pregnanciesl) and represents 0.4 per cent of all ectopic pregnancies. Approximately 200 cases of true ovarian pregnancies fulfilling the criteria of Spiegelberg are reported in the literature. To our knowledge, however, only one case of ovarian pregnancy with an intrauterine device in place has been published.2 Two additional cases of documented ovarian pregnancy with “in situ” intrauterine devices are herewith presented as a matter of interest.
Fig.
1. The
specimen
removed
at laparotomy
in Case 2.
Volume Number
108 4
Communications
The preoperative diagnosis of ruptured hemorrhagic corpus luteal cyst, however, was later changed after the pathologic findings reported a right ovarian pregnancy. Case 2. Mrs. S. M. (Metropolitan Hospital No. 079215) aged 22, para 4-O-O-4, with a last menstrual period of Aug. 24, 1968, was admitted on Nov. 24, 1968, in a state of shock. On pelvic examination the tails of a Lippes loop which had been inserted on Nov. 29. 1967, were present, protruding through the cervical OS. The cervix itself was soft, noncyanotic, and the uterus enlarged to approximately an 8 weeks size. There was suggestion of a mass palpable in the light adnexal region. Her chief complaint of spotting since her last missed period and a sudden onset of lower abdominal pain, together with her physical condition and a “positive” culdocentesis necessitated an immediate exploratory laparotomy. Upon entering the abdomen, a 14 cm. fetus was discovered free within the abdominal cavity which was filled with approximately 1,500 C.C. IIf free blood and clots. The uterus was enlarged to an 8 weeks size and intact. The left ovary and tube were grossly normal. The right tube was identified and its full extent found to be intact. The umbilical cord of the fetus was attached to a 10 Y 15 cm. hemorrhagic clotted mass. Clamping and excision of the mass was performed with removal of the distal portion of the right tube, the right ovary, and the attached placenta. The pathology report confirmed the suspicion of a right ovarian pregnancy. There was no pathology in the portion of the Fallopian tube submitted, the placenta was implanted in the ovarian parenchyma, and a corpus luteum of pregnancy was found in the specimen itself. X-rays postoperatively of the pelvis with diluted salpinx instilled into the uterine cavity showed the intrauterine device to be normally placed within the uterine cavity. These intrauterine
cases exemplify contraceptive
clearly devices
enough that are no barrier
to pctopic pregnancies of ovarian site or any location. In fact, they clearly point out that a correct and prompt diagnosis ought not be obscured or delayed by the presence of an intrauterine contraceptive device in situ. Hoth cases fultillcd pathologic criteria formulated by Spiegclhcrg in 1878 for ovarian pregnancy. Symptomatology in both cases did not differ from that of ectopic tubal pregnancy in general, namely, abnormal bleeding and pelvic pain. And as is usually the case in ovarian pregnancy, diagnosis was not made untii after exploration of the abdomen with confirmation or correction of the original diagnosis pathology report.
dependent
on the
final
in brief
673
REFERENCES
1.
2.
Personal communication with Drs. Sarah Lewit and Christopher Tietze on latest data of Population Council at time of submission of article, March, 1969. Piwer. M. S., Baer, K. A.. and Zachary. T 17.: J. A. M. A. 201: 323, 1967. 1901 New
First York,
Avenue New York
10029
Cervical mucus in cystic A possible cause of infertility EDWARD
ANTHONY
OPPENHEIMER, ARNOLD JOHN RICHARD
fibrosis:
M.D.
L. R.
CASE,
M.D.
ESTERLY, M.
Cystic Fibrosis Chicago School of the Department Department of the Department Department of
ROTHBERG.
M.D.* M.D.
Unit
of the University 01 the Chect Section of Medicine, the Obstetrics and Gynecologs, of Pathology, and the Pediatrics, Chicago, Il&ujir of Medicine;
c o N s I u E R A B I. E research has been focused on the physiology of human cervical ~II~..us.~-~ The abnormally viscid mucus secretions in cystic fibrosis of the pancreas (CF) lead to characteristic obstructive and suppurative complications. To our knowledge this is the first repott of a viscid cervical mucus plug and endocc%rvical polyp in cystic fibrosis. This 22-year-old woman with CF was evaluated for oligomenorrhea. Since age 6 she had had progressive severe respiratory problems. The diagnosis of CF was confirmed at age 13 (swear electrolytes: Na = 152 mEq. per liter, and Cl ‘:I 144 mEq. per liter). Steatorrhea due to pancreatic insufficiency has been well controlled medically. Menarche occurred at age 13. Menstrual periods were initially regular, every 30 days. with -I to 5 days’ flow. At about age 19, menstrual periods became irregular at approximately 3 month intervals with scant flow. She denied dysmenrlrrhea. Endocrine studies were normal. On examination the breasts and other secondary female sexual characteristics were well developed. The v&a and vagina were normal; the hymen was intact.
Communications
October. 15, 19x
in brief
Amer.
change found at the initial laparotomy in Case 2. Ideally, drainage of the appropriate cervix should have been sufficient. However, in Case 1 the abnormality was not recognized until laparotomy, when attempts were unsuccessful, and in Case 2 the pathology was not even appreciated at the first laparotomy. Successful treatment was achieved by excision of the infected hemiuterus in both. REFERENCES
1. 2. 3. 4.
5.
Merckel, G. C., Sucoff, M. C., and Sender, B.: AMER. J. OBSTET. GYNEC. 80: 70, 1960. Sampson, J. A.: Trans. Amer. Gynec. Sot. 52: 171, 1927. Scott, R. B., and Te Linde, R. W.: AMER. J. OBSTET. GYNEC. 60: 1147, 1950. Scott, R. B., Te Linde, R. W., and Wharton, L. R.: AMER. J. OBSTET. GYNEC. 66: 1082, 1953. Jeffcoate, T. N. A.: Principles of Gynaecology, London, 1962, Butterworth & Company, Ltd., p. 163.
Ovarian pregnancy with IUCD: Report of 2 cases ANTHONY ROBERT J.
VICTOR
PANE, SABATALLE, REYNIAK,
J. Obstet.
Gyncc.
Case 1. Miss C. U. (No. 14-42-30-FFAH), a 23-year-old primigravida, with a last menstrual period of Aug. 8, 1967, was admitted on Aug. 27, 1967, with the chief complaint of severe right lower quadrant pain. Nine days prior to admission, she had consulted her physician because of vaginal staining of 10 days’ duration. At that time, a right adnexal mass, approximately 5 X 5 cm. in size was palpated. An immunologic pregnancy test taken was negative. Physical examination revealed a moderately distressed female: blood pressure 100/40, pulse 100. There was diffuse lower abdominal tenderness with marked rebound tenderness in the right lower quadrant and diminished bowel sounds. The cervix was firm, noncyanotic, and moderately tender on motion. The tails of a Lippes loop inserted by her private doctor on April 9, 1967, protruded through the external OS. The uterus was normal size and freely mobile and the right adnexa suggested an ill-defined mass. Examination under anesthesia confirmed a right adnexal mass and culdocentesis produced 10 C.C. of unclotted blood. Upon exploration of the abdomen, approximately 1,000 C.C. of free blood in the peritoneal cavity was found which appeared to have come from a ruptured hemorrhagic cyst of the right ovary. The uterus, both tubes, and left ovary were grossly normal. A right ovarian cystectomy was performed.
in situ
M.D. M.D. M.D.
New York Medical College-Metropolitan Hospital Center, New York, New York E c T o P I c pregnancies with intrauterine devices in place are not uncommon occurrences. Recent statistics from the Population Council show 45 ectopic pregnancies out of 1,046 total pregnancies with diagnosed “in situ” intrauterine devices of all kinds, an estimate of approximately 1:23 pregnancies.l The incidence, moreover, of ectopic “ovarian” pregnancy is smaller (about 1: 25,000 pregnanciesl) and represents 0.4 per cent of all ectopic pregnancies. Approximately 200 cases of true ovarian pregnancies fulfilling the criteria of Spiegelberg are reported in the literature. To our knowledge, however, only one case of ovarian pregnancy with an intrauterine device in place has been published.2 Two additional cases of documented ovarian pregnancy with “in situ” intrauterine devices are herewith presented as a matter of interest.
Fig.
1. The
specimen
removed
at laparotomy
in Case 2.
Volume Number
108 4
Communications
The preoperative diagnosis of ruptured hemorrhagic corpus luteal cyst, however, was later changed after the pathologic findings reported a right ovarian pregnancy. Case 2. Mrs. S. M. (Metropolitan Hospital No. 079215) aged 22, para 4-O-O-4, with a last menstrual period of Aug. 24, 1968, was admitted on Nov. 24, 1968, in a state of shock. On pelvic examination the tails of a Lippes loop which had been inserted on Nov. 29. 1967, were present, protruding through the cervical OS. The cervix itself was soft, noncyanotic, and the uterus enlarged to approximately an 8 weeks size. There was suggestion of a mass palpable in the light adnexal region. Her chief complaint of spotting since her last missed period and a sudden onset of lower abdominal pain, together with her physical condition and a “positive” culdocentesis necessitated an immediate exploratory laparotomy. Upon entering the abdomen, a 14 cm. fetus was discovered free within the abdominal cavity which was filled with approximately 1,500 C.C. IIf free blood and clots. The uterus was enlarged to an 8 weeks size and intact. The left ovary and tube were grossly normal. The right tube was identified and its full extent found to be intact. The umbilical cord of the fetus was attached to a 10 Y 15 cm. hemorrhagic clotted mass. Clamping and excision of the mass was performed with removal of the distal portion of the right tube, the right ovary, and the attached placenta. The pathology report confirmed the suspicion of a right ovarian pregnancy. There was no pathology in the portion of the Fallopian tube submitted, the placenta was implanted in the ovarian parenchyma, and a corpus luteum of pregnancy was found in the specimen itself. X-rays postoperatively of the pelvis with diluted salpinx instilled into the uterine cavity showed the intrauterine device to be normally placed within the uterine cavity. These intrauterine
cases exemplify contraceptive
clearly devices
enough that are no barrier
to pctopic pregnancies of ovarian site or any location. In fact, they clearly point out that a correct and prompt diagnosis ought not be obscured or delayed by the presence of an intrauterine contraceptive device in situ. Hoth cases fultillcd pathologic criteria formulated by Spiegclhcrg in 1878 for ovarian pregnancy. Symptomatology in both cases did not differ from that of ectopic tubal pregnancy in general, namely, abnormal bleeding and pelvic pain. And as is usually the case in ovarian pregnancy, diagnosis was not made untii after exploration of the abdomen with confirmation or correction of the original diagnosis pathology report.
dependent
on the
final
in brief
673
REFERENCES
1.
2.
Personal communication with Drs. Sarah Lewit and Christopher Tietze on latest data of Population Council at time of submission of article, March, 1969. Piwer. M. S., Baer, K. A.. and Zachary. T 17.: J. A. M. A. 201: 323, 1967. 1901 New
First York,
Avenue New York
10029
Cervical mucus in cystic A possible cause of infertility EDWARD
ANTHONY
OPPENHEIMER, ARNOLD JOHN RICHARD
fibrosis:
M.D.
L. R.
CASE,
M.D.
ESTERLY, M.
Cystic Fibrosis Chicago School of the Department Department of the Department Department of
ROTHBERG.
M.D.* M.D.
Unit
of the University 01 the Chect Section of Medicine, the Obstetrics and Gynecologs, of Pathology, and the Pediatrics, Chicago, Il&ujir of Medicine;
c o N s I u E R A B I. E research has been focused on the physiology of human cervical ~II~..us.~-~ The abnormally viscid mucus secretions in cystic fibrosis of the pancreas (CF) lead to characteristic obstructive and suppurative complications. To our knowledge this is the first repott of a viscid cervical mucus plug and endocc%rvical polyp in cystic fibrosis. This 22-year-old woman with CF was evaluated for oligomenorrhea. Since age 6 she had had progressive severe respiratory problems. The diagnosis of CF was confirmed at age 13 (swear electrolytes: Na = 152 mEq. per liter, and Cl ‘:I 144 mEq. per liter). Steatorrhea due to pancreatic insufficiency has been well controlled medically. Menarche occurred at age 13. Menstrual periods were initially regular, every 30 days. with -I to 5 days’ flow. At about age 19, menstrual periods became irregular at approximately 3 month intervals with scant flow. She denied dysmenrlrrhea. Endocrine studies were normal. On examination the breasts and other secondary female sexual characteristics were well developed. The v&a and vagina were normal; the hymen was intact.