- Email: [email protected]
THYROTOXICOSIS DUE TO " SILENT " THYROIDITIS
813 feel more confident of recognising the possibility of medication induced abnormalities, but we re-echo Dr Gompertz’s plea for more information in this area. we now
Children’s Hospital,
SEAMUS F. CAHALANE CATHERINE MULLINS.
Temple Street, Dublin 1.
THYROTOXICOSIS DUE TO " SILENT " THYROIDITIS
SiR,—We reported in abstract form,l and submitted for 5
publication,
cases
with similar clinical and
laboratory
findings to those reported by Papapetrou and Jackson (Feb. 15, p. 361). They felt that their patients represented of subacute thyroiditis with hyperthyroidism. cases However, lack of both tenderness and raised sedimentationand subsequent development of hypothyroidism in 1 lead us to suspect that similar clinical and laboratory findings in our patients may not be due to subacute thyroiditis. We subsequently took biopsy specimens from these thyroid glands and found a histological picture typical of Hashimoto’s thyroiditis. Thus, we feel that cases presenting with clinical hyperthyroidism and low radioactive-iodine uptake may represent Hashimoto’s thyroiditis, and definitive diagnosis must be made by biopsy. rate
case
William Beaumont Army Medical Center, El Paso, Texas 79920, U.S.A.
STEPHEN R. PLYMATE FRANKLIN B. GLUCK MARTIN L. NUSYNOWITZ.
THIRD-TRIMESTER UTERINE SEPSIS ASSOCIATED WITH SHIELD-TYPE INTRAUTERINE DEVICE
SIR,-Lately there have been reports of intrauterine contraceptive devices of the shield type being associated with mid-trimester septic abortions.22 We should like to report
a case
cardia. The second stage was completed in ten minutes by the application of Wrigley’s forceps. An extremely tight nuchal loop of cord had to be severed to allow delivery of a live but asphyxiated female infant weighing 1420 g. The Apgar scores were assessed as 2 at the one-minute recording, and after vigorous resuscitation, including intubation, as 6 at the five-minute recording. The placenta and membranes were delivered complete, but a thorough search failed to reveal the expected Dalkon shield. The lower segment was swept with a finger but no device was felt. The mother’s condition remained stable during labour and improved rapidly after delivery. She became afebrile in 24 hours. Six days after delivery, the Dalkon shield was seen on a plain radiological examination and was subsequently removed under general anaesthesia. Anaerobic organisms (Bacteroides) were cultured from the interperitoneal pus. The infant was foul-smelling and in septic shock shortly after delivery, requiring treatment with massive doses of kanamycin, clindamycin, and penicillin. Cultures grew Bacteroides organisms. Persisting respiratory difficulties, complicated later by intracerebral haemorrhage, resulted in death of the infant on the fifth
day. This case reinforces the view that if pregnancy occurs with the shield type of contraceptive device, then the device should be removed, assuming that the threads have not been drawn too high into the uterus. It seems that the multifilament threads on these devices can become a nidus of infection. Salpingitis is rare in pregnancy.3 We feel that the present case cannot be classified as such and that the fallopian tube was merely a conduit for the drainage of pus from the uterus into the abdominal cavity. Department of Obstetrics and
Gynæcology, University of Alberta, Edmonton, Alberta T6G 2E1,
of third trimester pregnancy infection involv-
device had been inserted six weeks before the last menstrual period, and that when pregnancy occurred the patient had assumed that the device had been expelled during a camping trip. However, her husband knew that the device was a Dalkonshield type and was certain that it had not been expelled. We now felt confident that we were dealing with an intrauterine infection, associated with a retained foreign body in the uterus. We abandoned attempts to halt labour by discontinuing the isoxsuprine. Intravenous clindamycin and gentamicin was started. Labour was soon established. The first stage lasted nine hours, throughout which there was a persistent fetal tachyPlymate, S. R., Nusynowitz, M. L., Gluck, F. B. Clin. Res. 1975, 23, 95A. 2. Hurt, W. G. Obstet. Gynec., N.Y. 1974, 44, 491. 1.
K. F. RAWLINSON.
Parliament
ing the Dalkon-shield device. A 24-year-old gravida-2, para-0, aborta-1(therapeutic suction curettage), attended her family physician in her second pregnancy which was essentially normal until 30 weeks’ gestation. Complaints of lower-abdominal discomfort, increased frequency of micturition, and loose bowel movements were then reported. An empirical diagnosis of urinary-tract infection was made, and therapy with oral ampicillin started. However, the symptoms did not abate, and the patient was admitted to hospital 2 days later with increased pain, a contracting uterus, and a fever of 38’5QC. Uterine size corresponded to the calculated period of gestation, and the cervix was long and closed. Intravenous ampicillin and isoxsuprine were started. After 4 hours’ observation, it was noted that the right lower quadrant of the abdomen was increasingly tender and now exhibited guarding and rebound tenderness. Laparotomy was therefore planned, with a suspected diagnosis of acute appendicitis, though the unusual nature of the illness was duly considered. At laparotomy, free yellow pus was found in the abdominal cavity, the appendix was long and not involved in an inflammatory process, and the same yellow pus was seen to be pouring from the right fallopian tube, which was red and somewhat cedematous. The appendix was removed, possibly injudiciously, the gridiron incision closed, and a separate drainage site established. Careful review of the history revealed that an intrauterine contraceptive
J. J. BOYD
Canada.
Advisory Committee
on
Alcoholism
Dr DAVID OwEN, Minister of State, Department of Health and Social Security, announced in the House of Commons on March 26 the names of the members of the Advisory Committee on Alcoholism. The committee had been set up, under the chairmanship of Prof. Neil Kessel, to advise, for an experimental period of 3 years, on services relating to alcoholism and, where appropriate, to promote their development. It was expected that the committee would appoint a special subgroup to play an active part in the planning and development of services for homeless alcoholics. The committee would have its first meeting at the end of April. Induction of Labour questions were raised in the House of Commons on March 25 concerning induced births. Mrs JOYCE BUTLER wanted to know how many hospital maternity units were inducing labour as an administrative convenience, what guidance was given to mothers on the effects of induction on themselves or their babies, and what provision was made in such units for mothers to decline induction if there was no medical need for it. In his reply, Dr DAVID OWEN, Minister of State for Health, said that induced births as a percentage of all hospital deliveries in England and Wales rose from 13-7% in 1963 to 31-5% in 1972. The reasons for this increase were but the Department of Health would being investigated, expect that a proposed induction would be fully discussed and agreed with the woman herself, who would have the same right to refuse induction as she had to refuse any other form of treatment offered to her. It was hoped that A number of
3.
Odendaal, H., De Kock,
M. S.
Afr. med. J. 1973, 47,
21.
Children’s Hospital,
SEAMUS F. CAHALANE CATHERINE MULLINS.
Temple Street, Dublin 1.
THYROTOXICOSIS DUE TO " SILENT " THYROIDITIS
SiR,—We reported in abstract form,l and submitted for 5
publication,
cases
with similar clinical and
laboratory
findings to those reported by Papapetrou and Jackson (Feb. 15, p. 361). They felt that their patients represented of subacute thyroiditis with hyperthyroidism. cases However, lack of both tenderness and raised sedimentationand subsequent development of hypothyroidism in 1 lead us to suspect that similar clinical and laboratory findings in our patients may not be due to subacute thyroiditis. We subsequently took biopsy specimens from these thyroid glands and found a histological picture typical of Hashimoto’s thyroiditis. Thus, we feel that cases presenting with clinical hyperthyroidism and low radioactive-iodine uptake may represent Hashimoto’s thyroiditis, and definitive diagnosis must be made by biopsy. rate
case
William Beaumont Army Medical Center, El Paso, Texas 79920, U.S.A.
STEPHEN R. PLYMATE FRANKLIN B. GLUCK MARTIN L. NUSYNOWITZ.
THIRD-TRIMESTER UTERINE SEPSIS ASSOCIATED WITH SHIELD-TYPE INTRAUTERINE DEVICE
SIR,-Lately there have been reports of intrauterine contraceptive devices of the shield type being associated with mid-trimester septic abortions.22 We should like to report
a case
cardia. The second stage was completed in ten minutes by the application of Wrigley’s forceps. An extremely tight nuchal loop of cord had to be severed to allow delivery of a live but asphyxiated female infant weighing 1420 g. The Apgar scores were assessed as 2 at the one-minute recording, and after vigorous resuscitation, including intubation, as 6 at the five-minute recording. The placenta and membranes were delivered complete, but a thorough search failed to reveal the expected Dalkon shield. The lower segment was swept with a finger but no device was felt. The mother’s condition remained stable during labour and improved rapidly after delivery. She became afebrile in 24 hours. Six days after delivery, the Dalkon shield was seen on a plain radiological examination and was subsequently removed under general anaesthesia. Anaerobic organisms (Bacteroides) were cultured from the interperitoneal pus. The infant was foul-smelling and in septic shock shortly after delivery, requiring treatment with massive doses of kanamycin, clindamycin, and penicillin. Cultures grew Bacteroides organisms. Persisting respiratory difficulties, complicated later by intracerebral haemorrhage, resulted in death of the infant on the fifth
day. This case reinforces the view that if pregnancy occurs with the shield type of contraceptive device, then the device should be removed, assuming that the threads have not been drawn too high into the uterus. It seems that the multifilament threads on these devices can become a nidus of infection. Salpingitis is rare in pregnancy.3 We feel that the present case cannot be classified as such and that the fallopian tube was merely a conduit for the drainage of pus from the uterus into the abdominal cavity. Department of Obstetrics and
Gynæcology, University of Alberta, Edmonton, Alberta T6G 2E1,
of third trimester pregnancy infection involv-
device had been inserted six weeks before the last menstrual period, and that when pregnancy occurred the patient had assumed that the device had been expelled during a camping trip. However, her husband knew that the device was a Dalkonshield type and was certain that it had not been expelled. We now felt confident that we were dealing with an intrauterine infection, associated with a retained foreign body in the uterus. We abandoned attempts to halt labour by discontinuing the isoxsuprine. Intravenous clindamycin and gentamicin was started. Labour was soon established. The first stage lasted nine hours, throughout which there was a persistent fetal tachyPlymate, S. R., Nusynowitz, M. L., Gluck, F. B. Clin. Res. 1975, 23, 95A. 2. Hurt, W. G. Obstet. Gynec., N.Y. 1974, 44, 491. 1.
K. F. RAWLINSON.
Parliament
ing the Dalkon-shield device. A 24-year-old gravida-2, para-0, aborta-1(therapeutic suction curettage), attended her family physician in her second pregnancy which was essentially normal until 30 weeks’ gestation. Complaints of lower-abdominal discomfort, increased frequency of micturition, and loose bowel movements were then reported. An empirical diagnosis of urinary-tract infection was made, and therapy with oral ampicillin started. However, the symptoms did not abate, and the patient was admitted to hospital 2 days later with increased pain, a contracting uterus, and a fever of 38’5QC. Uterine size corresponded to the calculated period of gestation, and the cervix was long and closed. Intravenous ampicillin and isoxsuprine were started. After 4 hours’ observation, it was noted that the right lower quadrant of the abdomen was increasingly tender and now exhibited guarding and rebound tenderness. Laparotomy was therefore planned, with a suspected diagnosis of acute appendicitis, though the unusual nature of the illness was duly considered. At laparotomy, free yellow pus was found in the abdominal cavity, the appendix was long and not involved in an inflammatory process, and the same yellow pus was seen to be pouring from the right fallopian tube, which was red and somewhat cedematous. The appendix was removed, possibly injudiciously, the gridiron incision closed, and a separate drainage site established. Careful review of the history revealed that an intrauterine contraceptive
J. J. BOYD
Canada.
Advisory Committee
on
Alcoholism
Dr DAVID OwEN, Minister of State, Department of Health and Social Security, announced in the House of Commons on March 26 the names of the members of the Advisory Committee on Alcoholism. The committee had been set up, under the chairmanship of Prof. Neil Kessel, to advise, for an experimental period of 3 years, on services relating to alcoholism and, where appropriate, to promote their development. It was expected that the committee would appoint a special subgroup to play an active part in the planning and development of services for homeless alcoholics. The committee would have its first meeting at the end of April. Induction of Labour questions were raised in the House of Commons on March 25 concerning induced births. Mrs JOYCE BUTLER wanted to know how many hospital maternity units were inducing labour as an administrative convenience, what guidance was given to mothers on the effects of induction on themselves or their babies, and what provision was made in such units for mothers to decline induction if there was no medical need for it. In his reply, Dr DAVID OWEN, Minister of State for Health, said that induced births as a percentage of all hospital deliveries in England and Wales rose from 13-7% in 1963 to 31-5% in 1972. The reasons for this increase were but the Department of Health would being investigated, expect that a proposed induction would be fully discussed and agreed with the woman herself, who would have the same right to refuse induction as she had to refuse any other form of treatment offered to her. It was hoped that A number of
3.
Odendaal, H., De Kock,
M. S.
Afr. med. J. 1973, 47,
21.