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Penetrating chorionepithelioma with rupture of uterus and fatal intra-abdominal hemorrhage
PENETRATING IJTERUS
AND
DAVID (From
CHORIONEPITHELIOMA FATAL
ROSENBLOOM,
the Obstetrics
Service
WITH
INTR,A-ABDOMINAL M.S.,
M.D.,
Los
of the Los Angeles
RUPTURE
OF
HEMORRHAGE ANGELES, Coudy
(~~ALIF. General
Hospital)
THE
literature on chorionepithelioma includes numerous examples of tlie ,bizarre course this interesting tumor may take. Devastating growth. rapidity may be contrasted with instances’ of spontaneous disappearance of a tumor which is, microscopically, highly anaplastic. This is a report of a classic hydatid-mdle-chorionepithelioma sequence with extensive penetration of the uterine wall, spontaneous rupture into the peritoneal cavity, and fatal hemorrhage. The Quarterly Cumulative Medica.1 Index for the preceding twenty years reveals several titles of questionably similar cases, but in each instance the report appeared in an obscure and inaccessible foreign publication. More instances of this sort have undoubtedly been observed but not reported. CASE REPORT
Y. O., a 24-year-old Japanese female (Hospital No. 754817), entered the Los Angeles County General Hospital on &!larch 9, 1941. With the aid of an interpreter, the following history was elicited: The patient asserted that she had never been pregant, but she passed a hydatid mole eight months before, in July, 1940. Subsequently, frequent irregular spotting and passage of clots occurred. On March 3, 1941, a week before entry, she was studied in another Los Angeles hospital because of an increase in the amount of spotting and frequent lower abdominal cramps; a positive urine Friedman test, radiologically negative lungs, moderately enlarged heart, and normal blood and urine were reported from this other hospital. The patient was not acutely ill, and in good general physical condition. Blood pressure was 112/68. Bimanual pelvic examination showed the corpus uteri symmetrically enlarged to the size of a three to four months’ pregnancy with a soft closed cervix and normal adnexal zones, with no masses. The red cell count was 3.8 million, hemoglobin 72 per cent, and leucocyt,e count 8,200, with a normal differential smear and a sedimentation rate of 26 mm. per hour. Urine examination was negative. A tentative diagnosis of threatened abortion was made, and she was placed on routine conservative therapy. On March 12, 1941, at 12:40 P.M., three days after admission, the patient suddenly went into shock, the pulse became weak and flickering, and the blood pressure dropped to 60/O. The resident and 1 had made hospital rounds an hour before, and the patient seemed quite well at the time. The red cell count was 2.4 million, hemoglobin 32 per cent, and leucocyte count 6,400. Careful bimanual pelvic examination showed generalized abdominal tenderness; the uterus was only indefinitely palpable, the posterior vaginal fornix was soft, doughy, and seemed to bulge shghtly. Shock therapy was administered immediately, including warm blankets, deep Trendelenburg position, and intravenous fluids. 133
134
AMER1CAN
JOTJRNAI,
Ol?
OBSTETRICS
AND
c:B~:ECOI,Oi:S
The staff members concurred in a diagnosis of massive intra-abdominal hemorrhage, possibly due to rupture of the uterus. Laparotomy was immediately performed, using field block procaine anesthesia with continuous oxygen inhalation. After incising the peritoneum, the abdominal cavity was found to be full of blood clots and liquid blood. A large mass of friable tumor tissue lay free in the cul-desac. There was a 4 by 2 cm. rent in the right superior aspect of the anterior wall of the uterus, with moderate bleeding issuing from the uterine cavity. A bluish nodule, 3 by 5 cm., occupied the anterior uterine wall near the cervix. On palpat,ion, the enbire uterus seemed very friable, the anterior wall and fundus were paper thin and mushy, and it was evident that hemorrhage could be controlled only by hysterectomy. The broad ligaments and adnexal attachments mere rapidly
Fig.
L-Specimen
showing
rupture
of uterus
due
to
penetrating
chorionepithelioma.
clamped and divided, and because the cervix could be readily rekacted upward, a cuff of vagina was incised around it and a rather easy total hysterectomy was performed. The vaginal opening was rapidly sut,ured. the adnexal stumps were joined and attached, and the abdomen was speedily closed. The patient was almost moribund upon arrival in the operating room, and despite a midoperative 500 C.C. titrated blood transfusion, continuous oxygen inhalation, and stimulants, she died during the course of the operat,ion. The pathologist reported : (1) Ch oriocarcinoma with perforation of the uterus; (2) de&dual reaction in the endometrium; (3) hyperplasia of the myometrium typical of pregnancy; (4) theca lutein cysts. Inability to communicate with the patient’s family precluded permission for autopsy. SUMMARY
A chorionepithelioma penetrated the uterine wall and resulted in spontaneous uterine rupture, extrusion of a free mass of tumor tissue into the peritoneal cavity, and fatal intra-abdominal hemorrhage.
AND
DAVID (From
CHORIONEPITHELIOMA FATAL
ROSENBLOOM,
the Obstetrics
Service
WITH
INTR,A-ABDOMINAL M.S.,
M.D.,
Los
of the Los Angeles
RUPTURE
OF
HEMORRHAGE ANGELES, Coudy
(~~ALIF. General
Hospital)
THE
literature on chorionepithelioma includes numerous examples of tlie ,bizarre course this interesting tumor may take. Devastating growth. rapidity may be contrasted with instances’ of spontaneous disappearance of a tumor which is, microscopically, highly anaplastic. This is a report of a classic hydatid-mdle-chorionepithelioma sequence with extensive penetration of the uterine wall, spontaneous rupture into the peritoneal cavity, and fatal hemorrhage. The Quarterly Cumulative Medica.1 Index for the preceding twenty years reveals several titles of questionably similar cases, but in each instance the report appeared in an obscure and inaccessible foreign publication. More instances of this sort have undoubtedly been observed but not reported. CASE REPORT
Y. O., a 24-year-old Japanese female (Hospital No. 754817), entered the Los Angeles County General Hospital on &!larch 9, 1941. With the aid of an interpreter, the following history was elicited: The patient asserted that she had never been pregant, but she passed a hydatid mole eight months before, in July, 1940. Subsequently, frequent irregular spotting and passage of clots occurred. On March 3, 1941, a week before entry, she was studied in another Los Angeles hospital because of an increase in the amount of spotting and frequent lower abdominal cramps; a positive urine Friedman test, radiologically negative lungs, moderately enlarged heart, and normal blood and urine were reported from this other hospital. The patient was not acutely ill, and in good general physical condition. Blood pressure was 112/68. Bimanual pelvic examination showed the corpus uteri symmetrically enlarged to the size of a three to four months’ pregnancy with a soft closed cervix and normal adnexal zones, with no masses. The red cell count was 3.8 million, hemoglobin 72 per cent, and leucocyt,e count 8,200, with a normal differential smear and a sedimentation rate of 26 mm. per hour. Urine examination was negative. A tentative diagnosis of threatened abortion was made, and she was placed on routine conservative therapy. On March 12, 1941, at 12:40 P.M., three days after admission, the patient suddenly went into shock, the pulse became weak and flickering, and the blood pressure dropped to 60/O. The resident and 1 had made hospital rounds an hour before, and the patient seemed quite well at the time. The red cell count was 2.4 million, hemoglobin 32 per cent, and leucocyte count 6,400. Careful bimanual pelvic examination showed generalized abdominal tenderness; the uterus was only indefinitely palpable, the posterior vaginal fornix was soft, doughy, and seemed to bulge shghtly. Shock therapy was administered immediately, including warm blankets, deep Trendelenburg position, and intravenous fluids. 133
134
AMER1CAN
JOTJRNAI,
Ol?
OBSTETRICS
AND
c:B~:ECOI,Oi:S
The staff members concurred in a diagnosis of massive intra-abdominal hemorrhage, possibly due to rupture of the uterus. Laparotomy was immediately performed, using field block procaine anesthesia with continuous oxygen inhalation. After incising the peritoneum, the abdominal cavity was found to be full of blood clots and liquid blood. A large mass of friable tumor tissue lay free in the cul-desac. There was a 4 by 2 cm. rent in the right superior aspect of the anterior wall of the uterus, with moderate bleeding issuing from the uterine cavity. A bluish nodule, 3 by 5 cm., occupied the anterior uterine wall near the cervix. On palpat,ion, the enbire uterus seemed very friable, the anterior wall and fundus were paper thin and mushy, and it was evident that hemorrhage could be controlled only by hysterectomy. The broad ligaments and adnexal attachments mere rapidly
Fig.
L-Specimen
showing
rupture
of uterus
due
to
penetrating
chorionepithelioma.
clamped and divided, and because the cervix could be readily rekacted upward, a cuff of vagina was incised around it and a rather easy total hysterectomy was performed. The vaginal opening was rapidly sut,ured. the adnexal stumps were joined and attached, and the abdomen was speedily closed. The patient was almost moribund upon arrival in the operating room, and despite a midoperative 500 C.C. titrated blood transfusion, continuous oxygen inhalation, and stimulants, she died during the course of the operat,ion. The pathologist reported : (1) Ch oriocarcinoma with perforation of the uterus; (2) de&dual reaction in the endometrium; (3) hyperplasia of the myometrium typical of pregnancy; (4) theca lutein cysts. Inability to communicate with the patient’s family precluded permission for autopsy. SUMMARY
A chorionepithelioma penetrated the uterine wall and resulted in spontaneous uterine rupture, extrusion of a free mass of tumor tissue into the peritoneal cavity, and fatal intra-abdominal hemorrhage.