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Transabdominal encephalocentesis in breech presentation
592
Communications m brief
other 2 patients had no known follow-up. In the majority of these surgical procedures, the tumor was not removed completely; this observation has been reported as a problem in other vaginal carcinomas. 7 From these limited data, it appears that primary mesonephric adenocarcinoma of the vagina responds best to surgery combined with radiation or to radiation alone. :\ case of primary mesonephric adenocarcinoma of the vagina has been presented with an analysis of the II previously reported cases. This is a rare form of malignancy of the vagina and has several interesting features. Five of these cases occurred in children under age 16 years and only 4 in persons more than 50 years of age. The usual location for this type of malignancy is the anterolateral region of the vagina, and it responds best to radiation therapy, either alone or combined with surgical pro<'edures. REFERENCES
I. Messelt, 0. T.: Surg. Gynec. & Obst. 95: 1:1
JI,
1nr::o
l~JL;.
2. Novak, E., Woodruff, J. D., and Novak, E. R.: AM. J. OssT. & GYNEC. 68: 1222, 1954. 3. Palumbo, L., Jr.: South. M. J. 47: 356, 1954. 4. Plate, W. P.: Gynaecologia 130: 203, 1950. 5. Rutledge, F., Kotz, H. L., and Chang, S. C.: Obst. & Gynec. 25: 362, 1965. 6. Sheets, J. L., Dockerty, M. B., Decker, D. G., and Welch, J. S.: AM. J. 0BST. & GYNEC. 89: 121, 1964. 7. Smith, F. R.: Ann. New York Acad. Sc. 114: 1012, 1964. 8. Studdiford, W. E.: AM. J. 0BST. & GYNEC. 73: 641, 1957. 9. Teilum, G.: Acta path. et microbiol. scan,.
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10. Way, S.: J. Obst. & Gynaec. Brit. Emp. 55: 739, 1948. 107 East Perimeter San Antonio, Texas 78227
Transabdominal encephalocentesis in breech presentation STUART L. BEDNOFF, M.D. BARNET DELSON, M.D., F.A.C.O.G. Division of Obstetrics and Gynecology, North Shore Hospital, Manhasset, New York
T H E v A a r N A L delivery of a hydrocephalic fetus is often an extremely difficult and hazardous
June 15, 1966 Am. ]. Obst. & Gynec.
procedure. Transabdominal encephalocentesis can markedly simplify the problem and significantly decrease the risk to both mother and baby. The technique was first suggested by Wilson 3 in 1937, but few reports have appeared in the literatur~ since that time. Our familiarity with transabdominal amniocentesis for procedures designed to obtain amniotic fluid samples, gave us the courage to perform a transabdominal encephalocentesis upon a woman in active labor with a hydrocephalic fetus in a breech presentation. A 44-year-old white married para 6-0-0-6 female was admitted at term in active labor on April 4. 1965. The antepartum course had been uneventful. The patient's 6 previous pregnancies had been normal and the children are alive and well. A frank breech was diagnosed with the presenting part at -3 station. The cervix was 3 em. dilated and minimally effaced. Membranes were intact and the fetal heart was normal. Despite good contractions for 8 hours, little progress was made. A roentgen study of the abdomen revealed a frank breech presentation and a marked hydrocephalus. After voiding, the patient was surgically prepared. The fetal skull was steadied as an area of skin of the abdominal wall overlying it was infiltrated with 1 per cent lidocaine. A 6 inch, No. 18 gauge spinal needle was then passed throush the maternal abdominal cavity into the fetal calvarium without difficulty. Four hundred and fifty cubic centimeters of clear fluid was drained off slowly over a 20 minute period. At this time, the needle was noted to bend with each contraction and the flow of fluid diminished. It was now thought advisable to desist even though more fluid was present. No change in the patient's vital signs were recorded during or after the procedure. The fetal heart remained unchanged. The labor improved and 4 hours later the breech presented at the introitus. Under general anesthesia plus a pudendal block, delivery of the trunk and extremities was performed with ease. The fetal head was still large enough to impede delivery and transvaginal decompression was necessary. Using a 6-inch spinal needle, 1,000 c.c. of fluid was obtained. Delivery of the fetal head followed spontaneously. The infant was a stillborn male, weighing 3,880 grams. Blood loss during the entire procedure was minimal. The postpartum course was uneventful. The transabdominal removal of cerebrospinal fluid from a breech hydrocephalus is a safe and easily performed procedure. The technique to be used is described above. An x-ray of the abdomen is a helpful adjunct in locating the position at which to enter the fetal calvarium. It is important to note that even though all the fluid was not removed in this case via the transabdominal tap, the procedure made the vaginal tap easier
Volunw 9:1
Communications
Numho' r4
10
brief
593
to perform. Instead of removing the fluid by means of a No. 18 gauge spinal needle as was used in this case, we advocate the use of a No. 16 ga uge spinal needle to enter the calvarium and then insertion of a polyethyeline tubing of adequate caliber which will remain in place throughout labor. The fluid can continue to drain slowly throughout labor and the need for transvaginal decompression will be obviated. Further, the interruption of the procedure caused by bending of a metal needle would be avoided. The procedure is ethical and religiously accep ~ able, since no attempt is mad e to destroy the fetus.~ Adequate early decompression of the hydrocephalic head will prevent prolonged overdistension of the uterus and thereby avoid two of the mo:;t feared complications in obstetrics, rupture of the uterus and postpartum hemorrhage. 1
REFERENCES 1. Fara, F. J., Foss, H . G., and Philipp, C. A.:
AM . .J. 0BST. & GYNEC. 67: 158, 1954. 2. Lauderdale, J.: Obst. & Gynec. 23: 938, 1964. 3. Wilson, J. S.: Prenatal and Postnatal Management, Baltimore, 1937, William Wood & Company.
Maternal age and the source of the X chromosome in an XO girl
Fig. 1. Patient S. R., aged I 0 years. :i'iote webbing of the neck and the great numb!"r of pigm('ntcd ll i" Vi.
Xg
K. BOCZKOWSKI , M.D.* Department of Clinical Endocrinology, Medical Academy in Warsaw, Poland
THE MARK Eo increase in maternal age in autosomal trisomies supports the hypothesis that these trisomies are the result of meiotic nondisjunction in the mother. This age effect is much less striking in Klinefelter's syndrome, and is absent in Turner's syndrome.1 In the case of Turner's syndrome presented below, in spite of the advanced age of the mother, Xg blood group studies revealed that maternal nondisjunction was not the cause of the daughter's 45 j XO karyotype. The patient S. R., a 10-year-old girl, was a typical case of Turner's syndrome. The mother was 43 years old and the father 33 years old at the time of conception. The height was 118 em. *Present address: Chromosome Unit, 30 Hope Street, Liverpool, England.
f2
0
/
Q !lWiJ. FE/oW£
•
TURNER's SYNDROHE
Fig. 2. Pedigree of the family. Age given below symbols. Solid black symbol indicates patient S. R. with 45/XO karyotype. The chest was barrel-shaped with widely separated nipples, and the neck was short and webbed (Fig. 1 ) . External genitals were infantile. The labia minora were rudimentary and developed only in the upper third. At laparotomy typical gonadal streaks were
Communications m brief
other 2 patients had no known follow-up. In the majority of these surgical procedures, the tumor was not removed completely; this observation has been reported as a problem in other vaginal carcinomas. 7 From these limited data, it appears that primary mesonephric adenocarcinoma of the vagina responds best to surgery combined with radiation or to radiation alone. :\ case of primary mesonephric adenocarcinoma of the vagina has been presented with an analysis of the II previously reported cases. This is a rare form of malignancy of the vagina and has several interesting features. Five of these cases occurred in children under age 16 years and only 4 in persons more than 50 years of age. The usual location for this type of malignancy is the anterolateral region of the vagina, and it responds best to radiation therapy, either alone or combined with surgical pro<'edures. REFERENCES
I. Messelt, 0. T.: Surg. Gynec. & Obst. 95: 1:1
JI,
1nr::o
l~JL;.
2. Novak, E., Woodruff, J. D., and Novak, E. R.: AM. J. OssT. & GYNEC. 68: 1222, 1954. 3. Palumbo, L., Jr.: South. M. J. 47: 356, 1954. 4. Plate, W. P.: Gynaecologia 130: 203, 1950. 5. Rutledge, F., Kotz, H. L., and Chang, S. C.: Obst. & Gynec. 25: 362, 1965. 6. Sheets, J. L., Dockerty, M. B., Decker, D. G., and Welch, J. S.: AM. J. 0BST. & GYNEC. 89: 121, 1964. 7. Smith, F. R.: Ann. New York Acad. Sc. 114: 1012, 1964. 8. Studdiford, W. E.: AM. J. 0BST. & GYNEC. 73: 641, 1957. 9. Teilum, G.: Acta path. et microbiol. scan,.
a1nav .
OA
A 011
.J"t: "t..JI,
1
n!:.'
A
I~JLf'.
10. Way, S.: J. Obst. & Gynaec. Brit. Emp. 55: 739, 1948. 107 East Perimeter San Antonio, Texas 78227
Transabdominal encephalocentesis in breech presentation STUART L. BEDNOFF, M.D. BARNET DELSON, M.D., F.A.C.O.G. Division of Obstetrics and Gynecology, North Shore Hospital, Manhasset, New York
T H E v A a r N A L delivery of a hydrocephalic fetus is often an extremely difficult and hazardous
June 15, 1966 Am. ]. Obst. & Gynec.
procedure. Transabdominal encephalocentesis can markedly simplify the problem and significantly decrease the risk to both mother and baby. The technique was first suggested by Wilson 3 in 1937, but few reports have appeared in the literatur~ since that time. Our familiarity with transabdominal amniocentesis for procedures designed to obtain amniotic fluid samples, gave us the courage to perform a transabdominal encephalocentesis upon a woman in active labor with a hydrocephalic fetus in a breech presentation. A 44-year-old white married para 6-0-0-6 female was admitted at term in active labor on April 4. 1965. The antepartum course had been uneventful. The patient's 6 previous pregnancies had been normal and the children are alive and well. A frank breech was diagnosed with the presenting part at -3 station. The cervix was 3 em. dilated and minimally effaced. Membranes were intact and the fetal heart was normal. Despite good contractions for 8 hours, little progress was made. A roentgen study of the abdomen revealed a frank breech presentation and a marked hydrocephalus. After voiding, the patient was surgically prepared. The fetal skull was steadied as an area of skin of the abdominal wall overlying it was infiltrated with 1 per cent lidocaine. A 6 inch, No. 18 gauge spinal needle was then passed throush the maternal abdominal cavity into the fetal calvarium without difficulty. Four hundred and fifty cubic centimeters of clear fluid was drained off slowly over a 20 minute period. At this time, the needle was noted to bend with each contraction and the flow of fluid diminished. It was now thought advisable to desist even though more fluid was present. No change in the patient's vital signs were recorded during or after the procedure. The fetal heart remained unchanged. The labor improved and 4 hours later the breech presented at the introitus. Under general anesthesia plus a pudendal block, delivery of the trunk and extremities was performed with ease. The fetal head was still large enough to impede delivery and transvaginal decompression was necessary. Using a 6-inch spinal needle, 1,000 c.c. of fluid was obtained. Delivery of the fetal head followed spontaneously. The infant was a stillborn male, weighing 3,880 grams. Blood loss during the entire procedure was minimal. The postpartum course was uneventful. The transabdominal removal of cerebrospinal fluid from a breech hydrocephalus is a safe and easily performed procedure. The technique to be used is described above. An x-ray of the abdomen is a helpful adjunct in locating the position at which to enter the fetal calvarium. It is important to note that even though all the fluid was not removed in this case via the transabdominal tap, the procedure made the vaginal tap easier
Volunw 9:1
Communications
Numho' r4
10
brief
593
to perform. Instead of removing the fluid by means of a No. 18 gauge spinal needle as was used in this case, we advocate the use of a No. 16 ga uge spinal needle to enter the calvarium and then insertion of a polyethyeline tubing of adequate caliber which will remain in place throughout labor. The fluid can continue to drain slowly throughout labor and the need for transvaginal decompression will be obviated. Further, the interruption of the procedure caused by bending of a metal needle would be avoided. The procedure is ethical and religiously accep ~ able, since no attempt is mad e to destroy the fetus.~ Adequate early decompression of the hydrocephalic head will prevent prolonged overdistension of the uterus and thereby avoid two of the mo:;t feared complications in obstetrics, rupture of the uterus and postpartum hemorrhage. 1
REFERENCES 1. Fara, F. J., Foss, H . G., and Philipp, C. A.:
AM . .J. 0BST. & GYNEC. 67: 158, 1954. 2. Lauderdale, J.: Obst. & Gynec. 23: 938, 1964. 3. Wilson, J. S.: Prenatal and Postnatal Management, Baltimore, 1937, William Wood & Company.
Maternal age and the source of the X chromosome in an XO girl
Fig. 1. Patient S. R., aged I 0 years. :i'iote webbing of the neck and the great numb!"r of pigm('ntcd ll i" Vi.
Xg
K. BOCZKOWSKI , M.D.* Department of Clinical Endocrinology, Medical Academy in Warsaw, Poland
THE MARK Eo increase in maternal age in autosomal trisomies supports the hypothesis that these trisomies are the result of meiotic nondisjunction in the mother. This age effect is much less striking in Klinefelter's syndrome, and is absent in Turner's syndrome.1 In the case of Turner's syndrome presented below, in spite of the advanced age of the mother, Xg blood group studies revealed that maternal nondisjunction was not the cause of the daughter's 45 j XO karyotype. The patient S. R., a 10-year-old girl, was a typical case of Turner's syndrome. The mother was 43 years old and the father 33 years old at the time of conception. The height was 118 em. *Present address: Chromosome Unit, 30 Hope Street, Liverpool, England.
f2
0
/
Q !lWiJ. FE/oW£
•
TURNER's SYNDROHE
Fig. 2. Pedigree of the family. Age given below symbols. Solid black symbol indicates patient S. R. with 45/XO karyotype. The chest was barrel-shaped with widely separated nipples, and the neck was short and webbed (Fig. 1 ) . External genitals were infantile. The labia minora were rudimentary and developed only in the upper third. At laparotomy typical gonadal streaks were