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Rectouterine fistula associated with the Cu-7 intrauterine contraceptive device
292
Communications
in brief
Fig. 4. ECG obtained by direct atria1 signal;
V, fetal
ventricular
fetal scalp electrode during signal; P, fetal premature
(116 b.p.m.), fetal atria1 signals (165 b.p.m.), and fetal ventricular signals (41 b.p.m.). The diagnosis of third-degree heart block was thus confirmed. A male infant weighing 3,300 grams was delivered vaginally, with Apgar scores of 6 and 8 at 1 and 5 minutes. Complete heart block persisted after birth, with additional findings suggesting combined right and left ventricular hypertrophy and right atria1 enlargement. The ventricular rate was 40 b.p.m. Slight cyanosis was observed, but no other abnormalities were noted. Cyanosis persisted and, at age 21 hours, a cardiac pacemaker was inserted. Thereafter, the heart rate ranged between 110 and 120 b.p.m. Despite the properly functioning pacemaker and assisted respiration, the infant died at 28 hours of age. Death was preceded by return of cyanosis and, ultimately, respiratory arrest. Postmortem
examination with
mild
pulmonic
revealed right atrial and ventricular
muscular
hypertrophy
valvular insufficiency,
and functional
widely patient
labor. M, Maternal QRS ventricular contraction.
complex;
A, fetal
trauterine fetal monitoring, AM. J. OBSTET. GYNECOL. 1115, 1974. 2. Anderson, G. G., and Hanson, T. M.: Chronic bradycardia, Obstet. Gynecol. 44: 896, 1974.
120:
fetal
Rectouterine fist& associated with the Cu-7 intrauterine contraceptive device R.
D.
PATCHELL,
M.D.
Department of Obstetrics and Gynecology, West Virginia University Medical Center, Charleston Division, Charleston, West Virginia
dilatation
tricuspid
and
ductus ar-
teriosus, aspiration of amniotic fluid with early bronchopneumonia, and passive congestion of viscera. No congenital anatomic heart lesion was found. Special histologic stains of the His bundle revealed no abnormalities. The postmortem findings are probably the result of hemodynamic changes and the cause of the heart block remains unknown.
The differential diagnosis of fetal bradycardia is of practical importance, for management varies depending upon whether the slow rate is a manifestation of fetal distress or represents heart block. In the case of CCHB detected antenatally, appropriate arrangements can be made in advance of delivery to evaluate and, if necessary, to treat the infant immediately following birth. The case reported here demonstrates that CCHB can be diagnosed before labor by means of Doppler and phonocardiography to detect discordant atrial and ventricular rates. CCHB should be suspected when the stethoscope and Doppler fetal purse detection reveal widely differing heart rates. REFERENCES
1. Sokol, R. J., Hutchinson, P., Krouskop, R. W., et al.: Congenital complete heart block diagnosed during in-
ENDOECTOCERVICAL fistula production by the copper-bearing limb of a malpositioned intrauterine contraceptive device, (IUD) has been reported by Rienprayina and associates’ and Cederqvist and Fuchs.* Each group reported an additional case of posterior perforation with the device removed through a posterior coIpotomy. Reports3, ’ indicate that the intraperitoneal copper-bearing device causes a more intense reaction than the non-copper-bearing IUD. Rapid envelopment by omentum may protect the bowel but laparotomy may be necessary for removal. The following case suggests that the malpositioned Cu-7 may cause rectouterine fistula formation. A 34-year-old woman, gravida 3, para 3, was investigated at a diagnostic clinic in April, 1975, because of “stomach problems” of six months’ duration. Barium enema studies were interpreted as showing a rectovaginal fistula. She was immediately referred for gynecologic evaluation and management. This overweight woman had experienced vague upper abdominal pains for many years. In March, 1974, she had Reprint requests: Dr. R. D. Patchell, Department of Obstetrics and Gynecology, Memorial Division, Charleston Area Medical Center, Charleston, West Virginia 25304.
Volume Number
Communications
11’6 2
in brief
293
barium enema, and sigmaidoscapy were then performed. No evidence of the previously demon&rated abnormality was no&. No leakage of bowel content into the vagina was demonstrated by enteric dye and vaginal tampon testing. She has remained afebrile. The cul-de-sac thickening and tenderness are now absent.
It is unlikely that the omentum in this obese lady would reach to the cul-de-sac. Thus, protective envelopment of the device might ntrt have tzcurred. The sequence of a normal lower bowel study, subsequent demonstration of a rectogenital fistuia, and failure to demonstrate any abnormality six weeks after removal of the device would strongly suggest a cause-and-effect relationship. The complete subsidence of symptomatology following the removal of the device substantiates this. Although perforation by an IUD is an uncommon occurrence, the possibility should be considered in any wearer who develops abdominal pain or intestinal tract symptomatology. REP EREMCES
Fig. 1. Barium enema showing the misplaced IUD the rectum with barium visualized in the vagina.
anterior
to
gastrointestinal, barium enema, and sigmoidoscopic examinations. No abnormalities were noted. She was advised to reduce and to discontinue oral contraceptive medication. At that time, a 01-7 IUD was inserted without difficulty by an experienced gynecologist. In October, 1974, a new pattern of abdominal pain and a change in bowel habits gradually occurred. At intervals of seven to 10 days, she had episodes of lower abdominal cramps with stools becoming hard and pelletlike. After two or three days, the pain ceased and bowel movements became loose. On several occasions she noticed a foul brown vaginal discharge. The menstruation pattern was unchanged. Examination revealed an IUD string and a small portion of an IUD at the external OS. Definite thickening and slight tenderness of the cul-de-sac were noticed. Examination revealed no evidence of a rectovaginal fistula. Sigmoidoscopy to 20 cm. revealed no abnormalities. She was afebrile. Review of the barium enema studies revealed extraluminal barium anterior fo the rectum and extending into the vagina. An intrauterine device was visible with the copper-bearing limb projecting into the collection of extraluminal barium (Fig. 1). The patient stated that following the barium enema she passed barium through the vagina. A presumptive diagnosis of rectouterine fistula secondary to a malpositioned Cu-7 was made. The device was removed without difficulty. Spontaneous closure was anticipated, and hysterography was considered to be contraindicated. She was advised to keep an accurate temperature record and to report immediately if any fever or increased pain occurred. On two occasions following the removal of the Cu-7, she passed gas from the vagina. During the following six weeks, the pain and intermittent constipation gradually ceased. Hysterography,
1. Rienprayina, D., Phaavausasi, S., and Somboonsuk, A.: Cervical perforation by the copper T intrauterine device, Contraception 7: 515, 1973. 2. Cederqvist, L., and Fuchs, F.: Cervical perforation by a copper T intrauterine device, AM. J. OBSTET. GYNECOL. 11% 854, 1974. 3. Tatum, H. J.: Metallic copper asan intrauterine contraceptive agent, AM. J. OBSTET. GYNECOL. 117: 602, 1973. 4. Newton, J., Elias, J., McEwen, J., and Mann, G.: Intrauterine contraception with the copper 7‘: Evaluation after two years, Br. Med. J. 17: 447, 1974.
Ultrasound localization of laminaria TIMOTHY
G.
DONALD Diagnostic Medicine, Portland,
C. Radiology. Univmity Oregon
LEE,
M.D.
BARNETT,
M.11
Division of Ultraround, School of of Oregon Health Scimcrs Cenkr.
THE u SE OF ultrasound B-mode scanning in the localization of intrauterine contraceptives hasbeen well establishedand previously reported.‘-’ ‘To our knowledge, use of ultrasound for localization of laminaria and detection of a displaced laminaria has not been reported.
With
increased
social acceptance of abortions Laminaria dig-data to acultrasound localization of lam-
and the reintroduction of
complish abortions,’ inaria may become increasingly important. Laminaria also has been used in intracavitarv application for
Reprint requests: Dr. Timothy G. Lee, Diagnostic ogy, Division of Ultrasound, University of Oregon Sciences Center, School of Medicine. Portland, 97201.
RadiolHealth Oregon
Communications
in brief
Fig. 4. ECG obtained by direct atria1 signal;
V, fetal
ventricular
fetal scalp electrode during signal; P, fetal premature
(116 b.p.m.), fetal atria1 signals (165 b.p.m.), and fetal ventricular signals (41 b.p.m.). The diagnosis of third-degree heart block was thus confirmed. A male infant weighing 3,300 grams was delivered vaginally, with Apgar scores of 6 and 8 at 1 and 5 minutes. Complete heart block persisted after birth, with additional findings suggesting combined right and left ventricular hypertrophy and right atria1 enlargement. The ventricular rate was 40 b.p.m. Slight cyanosis was observed, but no other abnormalities were noted. Cyanosis persisted and, at age 21 hours, a cardiac pacemaker was inserted. Thereafter, the heart rate ranged between 110 and 120 b.p.m. Despite the properly functioning pacemaker and assisted respiration, the infant died at 28 hours of age. Death was preceded by return of cyanosis and, ultimately, respiratory arrest. Postmortem
examination with
mild
pulmonic
revealed right atrial and ventricular
muscular
hypertrophy
valvular insufficiency,
and functional
widely patient
labor. M, Maternal QRS ventricular contraction.
complex;
A, fetal
trauterine fetal monitoring, AM. J. OBSTET. GYNECOL. 1115, 1974. 2. Anderson, G. G., and Hanson, T. M.: Chronic bradycardia, Obstet. Gynecol. 44: 896, 1974.
120:
fetal
Rectouterine fist& associated with the Cu-7 intrauterine contraceptive device R.
D.
PATCHELL,
M.D.
Department of Obstetrics and Gynecology, West Virginia University Medical Center, Charleston Division, Charleston, West Virginia
dilatation
tricuspid
and
ductus ar-
teriosus, aspiration of amniotic fluid with early bronchopneumonia, and passive congestion of viscera. No congenital anatomic heart lesion was found. Special histologic stains of the His bundle revealed no abnormalities. The postmortem findings are probably the result of hemodynamic changes and the cause of the heart block remains unknown.
The differential diagnosis of fetal bradycardia is of practical importance, for management varies depending upon whether the slow rate is a manifestation of fetal distress or represents heart block. In the case of CCHB detected antenatally, appropriate arrangements can be made in advance of delivery to evaluate and, if necessary, to treat the infant immediately following birth. The case reported here demonstrates that CCHB can be diagnosed before labor by means of Doppler and phonocardiography to detect discordant atrial and ventricular rates. CCHB should be suspected when the stethoscope and Doppler fetal purse detection reveal widely differing heart rates. REFERENCES
1. Sokol, R. J., Hutchinson, P., Krouskop, R. W., et al.: Congenital complete heart block diagnosed during in-
ENDOECTOCERVICAL fistula production by the copper-bearing limb of a malpositioned intrauterine contraceptive device, (IUD) has been reported by Rienprayina and associates’ and Cederqvist and Fuchs.* Each group reported an additional case of posterior perforation with the device removed through a posterior coIpotomy. Reports3, ’ indicate that the intraperitoneal copper-bearing device causes a more intense reaction than the non-copper-bearing IUD. Rapid envelopment by omentum may protect the bowel but laparotomy may be necessary for removal. The following case suggests that the malpositioned Cu-7 may cause rectouterine fistula formation. A 34-year-old woman, gravida 3, para 3, was investigated at a diagnostic clinic in April, 1975, because of “stomach problems” of six months’ duration. Barium enema studies were interpreted as showing a rectovaginal fistula. She was immediately referred for gynecologic evaluation and management. This overweight woman had experienced vague upper abdominal pains for many years. In March, 1974, she had Reprint requests: Dr. R. D. Patchell, Department of Obstetrics and Gynecology, Memorial Division, Charleston Area Medical Center, Charleston, West Virginia 25304.
Volume Number
Communications
11’6 2
in brief
293
barium enema, and sigmaidoscapy were then performed. No evidence of the previously demon&rated abnormality was no&. No leakage of bowel content into the vagina was demonstrated by enteric dye and vaginal tampon testing. She has remained afebrile. The cul-de-sac thickening and tenderness are now absent.
It is unlikely that the omentum in this obese lady would reach to the cul-de-sac. Thus, protective envelopment of the device might ntrt have tzcurred. The sequence of a normal lower bowel study, subsequent demonstration of a rectogenital fistuia, and failure to demonstrate any abnormality six weeks after removal of the device would strongly suggest a cause-and-effect relationship. The complete subsidence of symptomatology following the removal of the device substantiates this. Although perforation by an IUD is an uncommon occurrence, the possibility should be considered in any wearer who develops abdominal pain or intestinal tract symptomatology. REP EREMCES
Fig. 1. Barium enema showing the misplaced IUD the rectum with barium visualized in the vagina.
anterior
to
gastrointestinal, barium enema, and sigmoidoscopic examinations. No abnormalities were noted. She was advised to reduce and to discontinue oral contraceptive medication. At that time, a 01-7 IUD was inserted without difficulty by an experienced gynecologist. In October, 1974, a new pattern of abdominal pain and a change in bowel habits gradually occurred. At intervals of seven to 10 days, she had episodes of lower abdominal cramps with stools becoming hard and pelletlike. After two or three days, the pain ceased and bowel movements became loose. On several occasions she noticed a foul brown vaginal discharge. The menstruation pattern was unchanged. Examination revealed an IUD string and a small portion of an IUD at the external OS. Definite thickening and slight tenderness of the cul-de-sac were noticed. Examination revealed no evidence of a rectovaginal fistula. Sigmoidoscopy to 20 cm. revealed no abnormalities. She was afebrile. Review of the barium enema studies revealed extraluminal barium anterior fo the rectum and extending into the vagina. An intrauterine device was visible with the copper-bearing limb projecting into the collection of extraluminal barium (Fig. 1). The patient stated that following the barium enema she passed barium through the vagina. A presumptive diagnosis of rectouterine fistula secondary to a malpositioned Cu-7 was made. The device was removed without difficulty. Spontaneous closure was anticipated, and hysterography was considered to be contraindicated. She was advised to keep an accurate temperature record and to report immediately if any fever or increased pain occurred. On two occasions following the removal of the Cu-7, she passed gas from the vagina. During the following six weeks, the pain and intermittent constipation gradually ceased. Hysterography,
1. Rienprayina, D., Phaavausasi, S., and Somboonsuk, A.: Cervical perforation by the copper T intrauterine device, Contraception 7: 515, 1973. 2. Cederqvist, L., and Fuchs, F.: Cervical perforation by a copper T intrauterine device, AM. J. OBSTET. GYNECOL. 11% 854, 1974. 3. Tatum, H. J.: Metallic copper asan intrauterine contraceptive agent, AM. J. OBSTET. GYNECOL. 117: 602, 1973. 4. Newton, J., Elias, J., McEwen, J., and Mann, G.: Intrauterine contraception with the copper 7‘: Evaluation after two years, Br. Med. J. 17: 447, 1974.
Ultrasound localization of laminaria TIMOTHY
G.
DONALD Diagnostic Medicine, Portland,
C. Radiology. Univmity Oregon
LEE,
M.D.
BARNETT,
M.11
Division of Ultraround, School of of Oregon Health Scimcrs Cenkr.
THE u SE OF ultrasound B-mode scanning in the localization of intrauterine contraceptives hasbeen well establishedand previously reported.‘-’ ‘To our knowledge, use of ultrasound for localization of laminaria and detection of a displaced laminaria has not been reported.
With
increased
social acceptance of abortions Laminaria dig-data to acultrasound localization of lam-
and the reintroduction of
complish abortions,’ inaria may become increasingly important. Laminaria also has been used in intracavitarv application for
Reprint requests: Dr. Timothy G. Lee, Diagnostic ogy, Division of Ultrasound, University of Oregon Sciences Center, School of Medicine. Portland, 97201.
RadiolHealth Oregon