568

Communications

February Am. J. Obstet.

in brief

15, 1975 Gyn~col.

In conclusion, it seems apparent that presence 01 skeletal deformities should stimulate investigation of the genitourinary system. With identification of all Miillerian duct derivatives, judgment on reproductive potential and therapeutic approach is made. REFERENCES

1.

Baird,

P.

A., and Lowry, R. B.: AM. J. OBSTET. 118: 290, 1974. 2. Bryan, A. L., Nigro, J. A., and Counseller, V. S.: Surg. Gynecol. Obstet. 88: 79, 1949. 3. Carroll, R. E., and Louis, D. S.: J. Pediatr. 84: 409, 1974. 4. Turunen, A., and Unnerus, C. E.: Acta Obstet. Gynecol. Stand. 46: 99, 1967. 5. Jones, H. W., Jr., and Wheeless, C.: AM. J. OBSTET. GYNECOL. 104: 348, 1969. GYNECOL.

A mode of action of hypertonic in inducing abortion DEREK

LLEWELLYN-JONES

ALAN DON

Fig. 1. Radiograph of both formity of left extremity.

forearms

and

hands

with

de-

saline

CLARKE SHUTT

Department University

of Obstetrics of Sydney,

and Gynaecology, N.S.W. Australia

ABORTION in the second trimester of pregnancy is effected with the least trauma to the patient and with the lowest morbidity if one of the following two methods is used: ( 1) intrauterine injection of prostaglandin F,, or E,, and (2) intrauterine injection of 20 per cent hypertonic saline. In each in stance the abortifacient may be injected intra-amniotitally or into the extraovular (extra-amniotic) space. Both methods have advantages and disadvantages.4 The mode of action of prostaglandin is the induction of uterine activity, either directly or subsequent to the re-

THERAPEUTIC

located adjacent to normal-appearing ovaries. The right ovary showed a fresh ovulation point. Three months later, a McIndoe procedure was carried out with split-thickness skin graft from the right thigh. The postoperative course and follow-up were uneventful. Good coital function is reported. In a recent publication,r the Klippel-Feil anomaly associated with congenital absence of the vagina was reported in 2 patients of adolescent age. No mention was made of the status of the urinary tract. Among 100 cases of congenital absence of the vagina, urinary tract anomalies were present in 50 per cent of those patients studied.” Of 33 children with radial dysplasia, 50 per cent showed genitourinary anomalies among defects in many other organs3 The significance of this finding lies in the easy recognition of skeletal deformities in extremities and the occult presence of genitourinary anomalies. Defects in the genitourinary system are readily overlooked in the absence of clearly visible lesions. Among 200 cases of congenital absence of the vagina, normal menstrual function was restored in 5 patients, and pregnancy occurred in three.a The incidence of skeletal deformities was 12.5 per cent. Comparison of groups of patients with congenital absence of the vagina without uterine development and congenital absence of the vagina with uterine development suggests that the latter anomaly may be associated less frequently with renal abnormalities.5

lease of oxytocin. It is not clear how hypertonic saline induces uterine activity, although Gustaviie has suggested that this might be by its absorption into decidual cells which are then induced to release prostaglandin. It is known that decidual cells are rich in prostaglandins.3 Eight patients, informed of the procedure, were studied. The volunteers received extraovular hypertonic saline (7.5 to 10.0 ml. per completed gestational week). An epidural catheter was introduced into the amniotic sac by the amniocentesis technique within one hour of the injection of the saline solution via the cervical canal. Amniotic fluid samples were removed at 6 hour intervals until the abortion occurred and stored at -4” C. After the amniotic fluid was diluted 1:5 with phosphosaline buffer (pH 7.4)) the level of prostaglandin FaLy in the samples was measured by the radioimmunoassay method of Clarke and associates1

Volume Number

121 4

Communications

Table I. Prostaglandin F,, in amniotic fluid after administration of extraovular saline during the second trimester HOU7S

No. of patients

0 6 12 18 24 30 36 42 48 54

8 8 7 4 3 2 ‘2 2 2 2

Prostaglandin t;,, (ng.1 ml.) (mean or mean + S.E.) 0 0.6 1.1 2.1 3.3 2.5 4.1 5.3 6.4 8.4

+ 2 t +

0.2 0.3 0.9 0.7

The results are shown in Table I. From a basal of less than 0.6 ng. per milliliter, the concentration prostaglandin F,, in the amniotic fluid increased levels which are associated with progessive uterine ity. At this time abortion was in progress. Similar were found by Salmon and Amy” in amniotic fluid ples obtained during normal labor at term.

level of to activlevels sam-

REFERENCES

2. 3. 4. 5.

Clarke, A. &I., Shutt, D. A., and Jones, W. R.: I. R. C. S. Obstet. Gynecol. 2: 1050, 1974. Gustavii, B.: Acta Obstet. Gynecol. Stand. (Suppl.) 25: 1, 1973. Karim, S. M. M. : J. Reprod. Fertil. (Suppl.) 16: 105, 1972. Llewellyn-Jones, D., O’Toole, V. M., Reynolds, J., and Salleh, Y.: Amt. N. Z. J. Obstet. Gynaecol. In press. %;y, J. A., and Amy, J. J.: Prostaglandins 4: 523,

Ovarian JOHN

arteriovenous C.

WEED,

JR.

CHARLES

B. HAMMOND

J.

CLEMENT*

EDWIN

ROBERT Southeastern Department University

W.

fktula

MCCONNELL*

gestational

Uniand

RIOVE

N 0 u s

fistulas

are

rare

as

trophoblastic

disease.

C. R., a 29-year-old, white, married woman, para 5-2-3, was admitted on January 14, 1974, for evaluation of recurrent gestational trophoblastic disease. A hydatidiform mole was evacuated by hysterotomy followed by singleagent chemotherapy in 1965. She entered remission theresensitive human chorionic after, as judged by normal, gonadotropin (HCG) assays. Subsequently, she completed 3 term pregnancies and had a first-trimester abortion without difficulty. She underwent cesarean section delivery for each pregnancy and had a tubal ligation with the last operative delivery in September, 1970. There was no evidence of pelvic abnormality at operation. The patient presented at this time for evaluation of aching right lower quadrant pain. Menses were regular, and she noted no other associated symptoms. Physical examination revealed direct right lower quadrant tenderness with a pulsatile lower abdominal mass and a loud systolic bruit over the right side. Pelvic examination revealed an enlarged uterus of 6 weeks’ gestational size with a palpable vascular thrill along the right side of the uterus. The left adnexa and cul-de-sac were normal. Because of the past history of trophoblastic disease, a urine pregnancy test, which was positive, was obtained. A right percutaneous retrograde aortogram revealed a markedly dilated right ovarian artery with an arteriovenous malformation in the right adnexa (Fig. 1). The patient was referred to this Center for evaluation and therapy. Complete metastatic workup, including chest x-ray, intravenous pyelogram, brain and liver scans, electroencephalogram, electrocardiogram, hematologic studies, and serum chemistries were normal. Repeated serum radioimmunoassays (beta-subunit) were lkss than 5 m1.U. per milliliter (undetectable) for HCG. An exploratory operation for the arteriovenous fistula and enlarged uterus was performed on January 18, 1974. Operative findings confirmed the arteriographic findings of a right ovarian arteriovenous fistula and an enlarged, soft uterus of 8 weeks’ gestational size. Total abdominal hysterectomy, appendectomy, and right salpingo-oophorectomy were performed with individual triple ligation of the right ovarian artery at the pelvic brim. The left ovary was normal and was preserved. On the fifth postoperative day, the patient suffered

a major pulmonary

Regional Trophoblastic Disease Center, of Obstetrics and Gynecology, Duke Medical Center, Durham, North Carolina

Reprint requests: Dr. Charles B. Hammond, Duke versity Medical Center, Department of Obstetrics Gynecology, Durham, North Carolina 27710. *Present address: Greenville, North Carolina.

ARTE

569

demonstrated by the infrequent reports available in the modern literature.l-4 Congenital malformation and posttraumatic lesions are the usual accepted etiologies. Uterine fistulas have been reported after various gynecologic surgical procedures and normal deliveries.’ Arteriovenous shunting has been described in association with neoplastic disease, especially choriocarcinoma.” To our knowledge, no adnexal fistulas involving the ovarian arteries have been reported. The following case of a right ovarian arteriovenous fistula is reported in a young woman who previously was treated successfully for nonrnetastatic

The results suggest that one way in which hypertonic saline is effective in inducing second-trimester abortion is by stimulating the release of prostaglandin by decidual cells. These findings add support to Gustavii’s’ hypothesis.

1.

PELVIC

in brief

embolism, documented

by pulmonary

angiography. Immediate heparin anticoagulation treatment was instituted and continued for 10 days. She was converted to sodium warfarin without difficulty and was discharged on the eighteenth postoperative day. Pathologic review of the removed structures revealed an enlarged uterus with proliferative endometrium, a right corpus luteum cyst, and adnexal structures consistent with an arteriovenous malformation. No evidence of trophoblastic disease was noted. HCG titers have remained negative.

A mode of action of hypertonic saline in inducing abortion.

568 Communications February Am. J. Obstet. in brief 15, 1975 Gyn~col. In conclusion, it seems apparent that presence 01 skeletal deformities shou...
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