CONTRACE
T
T
P
S
IN
OF
0
N IN
ION
CASES
P
M i t chel i S. Ric rd L.
ib us, M. D. et, M . D .
Depar en= o f stetrics California Medical Center,
S
ecology, Un e r s l t y of San F r a n c i s c o , C a i i f o ia
CT
pail ts a I t t e d for s e c o tr ester abortions o d a or 1 f d i n g s on p e ic e x a ~ i t i o n and d i d t r e s p o n d to intraionic prostagl d i n ~2~ are p r e s ted. Both pati ts d abdominal pregn cy a '~he f d gs a cl ical course are p r e s ted.
Acc ep ted
MARCH
for
1976
pub 1 i c a t io n
VOL.
13 N O .
January
3
! 5,
19 7 6
385
CONTR
E
ION
!NTRODUCTI
Prostagla in F^ (PGF)~ h a s b e c o m e a n a c c e p t e d m e t h o d f o r second trimester pregnancy ~rmlnation(i, ). In o u r rst 350 trimester abortions utillz intra-a i o t i c PGF, w e e x p e r i e n c e d t failures associated with abd Inal pregnancies. B o t h of t h e s e pat ien t s had unc l i c a t ed i o c e n t e se s w l t h a f r e e f l o w o f iot ic fluid d uneventful piece n t o f t h e PGF. report these cases to a l e r t practitioners to t h i s p o s s i b i l i t y d to d r a w a t t e n t i o n to c l i n i c a l f e a t u r e s that m i g h t s u g g e s t s u c h a co llcation. Case
I
.G. s a 3~yea o l d g r a v i d a 2, p a r e 1 w l t h a Dece er 18, 1 9 7 3 . On M a r c h 2, 1 9 7 4 a n a te ted suction therapeutlc abortlon obtained only decidua, and a pre ancy test on rch 23rd s still posit e. A D and C s p e r f o r m e d o n ~ r c ~ .....2. 4 t h a n d ..~..e ~ no tissue was obta ed a s o n o g r s done ich s interpreted as showing intrauterine p r e g n a n c y . Three we s later she s referred to t h e i v e r s i t y of C a l i f o r n i a , S a n F r clsco, for a s e e o tr ester pregnancy term atlon. Ex i n a t l o n a t t h i s ti revealed a 20-25 diameter ss in t h e p e l v i s Ich w a s d o p p l e r p o s i t i v e f o r a f e t a l heart and ich s e l e v a t e d to the r i g h t b y a n 8 - 1 0 c m d i e ter ss p o s t e r i o r l y o n t h e l e f t . Although the larger ss s thought to b e t h e u t e r u s , the p o s s i b i l i t y of a c h r o n i c e c t o p i c p r e g n a n c y S d i scu s sed t h t h e p a t i e n t. A r epea t sonogr rcreeled a solid ss o n t h e l e f t in a d d i t i o n to a n i n t r a u t e r i n e p r e ency. A p r l l 22 she s a d m i t ted t o t h e h o s p i t a l a n d r o u t i n e ur Ine and blood s tudie s were with no r 1 i i t s. a i o c e n t e s is obtained clear a iotic fluid on the first art pt a n d 4 0 PGF was instilled intra-a iotlcaily. That evening she had a few mild c o n t r a c t i o n s b u t b y ~ o r n l n g t h e r e w a s n o c e r v i c a l e f fee e n t or dilatatlon, i n t r a v e n o u s p l t o c l n d r i p at. 75 nits/m was beg but en no uterine contractions occurred a laparoto s perfo d. The f d i n g s at s u r g e r y i n c l u d e d a n a n t e r i o r 8 - i 0 c m d l eter uterus with large bo i adher t to i t s c e p h a l a d s u r f a c e . Posterior ~d s u p e r i o r to t h e u t e r u s s a 20 c ~ d i eter iotic sac containing a 166 fetus ose cro -r l e n g t h w a s 12 cm. The placenta s attach to the posterior leaf of the broa~ /iga nt and the p o s t e r i o r s u r f a c e of t uterus ditionally, both fallopian tubes sho d gross evidence of chronic fection, one ovary s i ol d i n the a b d o m ai p r e g n a n c y , d t o er ovary s i olved in a ss o f t u b o - o rian adhesions. I n conj orlon i t h re val of the fetus d placenta, a total abdo~i 1 hysterecto and bilateral .s...a i p go--oop r e c to S per fo d. The posty opera ~ i course S and the pathology report the find gs de scribed above; there s n6 i d e n c e o f a ~c icat ion bet en t h e e n d o m e t r l a l c a v l t y a n d t h e a b d o ~ i n a i p r e g n a n c y .....
386
MARCH
1976
V O L . 13 N O . 3
CONTRACEI~FION
Case 2 D .B. s a 26 ear id g r i d a 2, p a 1 :wlth certain She s seen for pre y rlficatlon in the S Fr clsco neral spiral pr atal cl ic o n y i, 1 9 7 5 . A t t h a t tl s est teal'that h e r p r e cy s 22 s menstrual age based~ o n p h y s i c a l e inat~0n, the date "ofoquickenl ~ d ~SO g " Other f Ings cl ed a 6 c~ left ce i c a l ....~ ...a s s t ught to be a ielo a easily aud le fetai heart tones, y 21st she returned th a c iaint of not h inE f~It the fetus ve for o eks. e r e ~had ...b ..e no f dal gr th since t last visit d t h e f e t ~ l ~heart s not a ible. Sonogr rlfi fetal d se d nhe pres ce of po r s. ~y 27th she s a it ted t o t h e spltal and a urine alysis, CBC, p l a t e l e ~ co t, t h r in clottl t and set f rlno E re nor 1 1 its. iocentesis obna ed br tic id a 40 F s i n s t i i i ed i n t r a io t i C a ii y t ut cid t. No contra ions occurred with t n t y - f o u r h o u r s so a s e c o ~n~ectlon of 4 0 PGF s a istered intra~ iotically. Eight urs later her o 1 te era t s 38.1 C d cl Ical e dence of peritonitis s p~esent. A repeat iocentesls revealed 10-15 C per hi E po red field. ~ ...d .i a g sis of ~ ionltls s de d tray us penicillin and intr c k ther y s begun. Si e there had b no contractions and no cervical e f facem t o r d i i a ta t ion, t dec i sion s de n o e~p t y the ut e rus by hysteroto . The f d g s at s u r g e r y i n c l u d e d a n terior 8 x 5 cm uterus. P o s t e r i o r a n d s u p e r i o r to t h e u t e r u s s a 14 c ~ d i a ter iotlc sac c o n t a i n i n g a 1 7 0 fetus se cr -ru ~length s ° 12"....cm. .. The placenta s a t t a c h e d to t h e p o s t e r i o r s u r f a c e of t h e u t e r u s , ! e f t b'road- i ig nt ~ fa !i o p Jan. t e d o v a r y. d it i o n a l f ing s ciuded a right tubo ovarian cess. ~ total abdo al hysterecto a bilateral~salplngo-oophorect s perfo d to r ve the p i acent a d f e t u S. oT h e p o s t o p e r a t e tour se s ev t ful. ~he pat logy report confir d the find gs descr ed abo d de nstrated that the left fallopian tube s t original site o f the pregnancy. DISCUSSI T se t cases had a n er of s il clinlcai lea re8 ich should alert the ob.stetrici to t possib ity of do al preg ncy. th had r i fi inEs on pel c ex ation d did not respo to intr iotic P . addition, the first pail t had no !ntra'uter e pro c t s of' C Ceptlon On t curretages. e so gram in each case s i n t e r p r e t e d a s .... i n t r a ' u t e r e pre y th a sol pelvic ss ~ s u g g e s t i n g a l e i d i d n o t .a
MARCH
76
.
. 3
387
C
TRACE
1
in a r r g at the c o r r e c t d i a osis. It is c l e a r that a s u c c e s s f u l io c t es is a co licat ed ins t i l l a t l o n o f P G F d o e s no t a s s u r e the p r e s e n c e o f intra-uter e pre ahoy. If i n t r a i o t i c P G F a s s e r t s its e f f e c t l o c a l l y r a t h e r t by syst ic a b s o r p t i o n d redistr u t i o n ,th the i k of u t e r i n e response o u r e a s e s is r e a d i l y .... e r s t o o d ( 3 ) , ers i n o u r e eri ce 8% of the p a t i e n t s r e q u i r e a s e c o n d i n s t i l l a t i o n of F to i u c e labor. T h e r e f o r e ~ f a i l u r e of u t e r i n e r e s p o n s e to t ra-a iot d o e s no t, b y i t self ~ n e c es sar i l y i icat e i situation, w er~ w e s u g g e s t that t ~ a i i u r e of u t e r i n e r e s p o n s e t o P G F in a s s o c i a t i o n w i t h nor i findings on pelvic e nation~ d a so g r a m i n t e r p r e t e d as a s o l i d ss c o n t i g u o u s w i t h the p r e a n c y s h o u l d a l e r t the p h y s i c i a n to the p o s s illty of o m l n a l pre ahoy.
0 Co
G : wish y for s u p p l y i n g the
. Ted So e r n of T h e U p j o iD P2~ (Prostin, T h salt).
REF I. int
ES
d Sha , SD. S e c o n d - t r ester a b o r t i o n i o t i c i n j e c t i o n of p r o s t a g l a n d l n s E 2 and F2e.
-
single ncet
2 :4 7-4 8 (i 97 i) 2.
C or son, SL, B o l o ~ e s e 0 , , and rola, J. prostagl d F to i n d u c e m i d t r ester
Ob s te t C 3.
eco i ~ ~ 7 :2 7-34
tra-a ortion,
iot ic er J
(i 9 73)
ghlssl, K S a n d tray, CP. T h e f u n c t i o n of p r o s t a g l d in r e p r o d u c t i o n . O b s t e t G e c o l Su ey 2 5 - 2 8 1 - 2 9 6 (1972)
s
°4
~ AR
t976
VOL.
NO.
3
T
T
P
S
IN
OF
0
N IN
ION
CASES
P
M i t chel i S. Ric rd L.
ib us, M. D. et, M . D .
Depar en= o f stetrics California Medical Center,
S
ecology, Un e r s l t y of San F r a n c i s c o , C a i i f o ia
CT
pail ts a I t t e d for s e c o tr ester abortions o d a or 1 f d i n g s on p e ic e x a ~ i t i o n and d i d t r e s p o n d to intraionic prostagl d i n ~2~ are p r e s ted. Both pati ts d abdominal pregn cy a '~he f d gs a cl ical course are p r e s ted.
Acc ep ted
MARCH
for
1976
pub 1 i c a t io n
VOL.
13 N O .
January
3
! 5,
19 7 6
385
CONTR
E
ION
!NTRODUCTI
Prostagla in F^ (PGF)~ h a s b e c o m e a n a c c e p t e d m e t h o d f o r second trimester pregnancy ~rmlnation(i, ). In o u r rst 350 trimester abortions utillz intra-a i o t i c PGF, w e e x p e r i e n c e d t failures associated with abd Inal pregnancies. B o t h of t h e s e pat ien t s had unc l i c a t ed i o c e n t e se s w l t h a f r e e f l o w o f iot ic fluid d uneventful piece n t o f t h e PGF. report these cases to a l e r t practitioners to t h i s p o s s i b i l i t y d to d r a w a t t e n t i o n to c l i n i c a l f e a t u r e s that m i g h t s u g g e s t s u c h a co llcation. Case
I
.G. s a 3~yea o l d g r a v i d a 2, p a r e 1 w l t h a Dece er 18, 1 9 7 3 . On M a r c h 2, 1 9 7 4 a n a te ted suction therapeutlc abortlon obtained only decidua, and a pre ancy test on rch 23rd s still posit e. A D and C s p e r f o r m e d o n ~ r c ~ .....2. 4 t h a n d ..~..e ~ no tissue was obta ed a s o n o g r s done ich s interpreted as showing intrauterine p r e g n a n c y . Three we s later she s referred to t h e i v e r s i t y of C a l i f o r n i a , S a n F r clsco, for a s e e o tr ester pregnancy term atlon. Ex i n a t l o n a t t h i s ti revealed a 20-25 diameter ss in t h e p e l v i s Ich w a s d o p p l e r p o s i t i v e f o r a f e t a l heart and ich s e l e v a t e d to the r i g h t b y a n 8 - 1 0 c m d i e ter ss p o s t e r i o r l y o n t h e l e f t . Although the larger ss s thought to b e t h e u t e r u s , the p o s s i b i l i t y of a c h r o n i c e c t o p i c p r e g n a n c y S d i scu s sed t h t h e p a t i e n t. A r epea t sonogr rcreeled a solid ss o n t h e l e f t in a d d i t i o n to a n i n t r a u t e r i n e p r e ency. A p r l l 22 she s a d m i t ted t o t h e h o s p i t a l a n d r o u t i n e ur Ine and blood s tudie s were with no r 1 i i t s. a i o c e n t e s is obtained clear a iotic fluid on the first art pt a n d 4 0 PGF was instilled intra-a iotlcaily. That evening she had a few mild c o n t r a c t i o n s b u t b y ~ o r n l n g t h e r e w a s n o c e r v i c a l e f fee e n t or dilatatlon, i n t r a v e n o u s p l t o c l n d r i p at. 75 nits/m was beg but en no uterine contractions occurred a laparoto s perfo d. The f d i n g s at s u r g e r y i n c l u d e d a n a n t e r i o r 8 - i 0 c m d l eter uterus with large bo i adher t to i t s c e p h a l a d s u r f a c e . Posterior ~d s u p e r i o r to t h e u t e r u s s a 20 c ~ d i eter iotic sac containing a 166 fetus ose cro -r l e n g t h w a s 12 cm. The placenta s attach to the posterior leaf of the broa~ /iga nt and the p o s t e r i o r s u r f a c e of t uterus ditionally, both fallopian tubes sho d gross evidence of chronic fection, one ovary s i ol d i n the a b d o m ai p r e g n a n c y , d t o er ovary s i olved in a ss o f t u b o - o rian adhesions. I n conj orlon i t h re val of the fetus d placenta, a total abdo~i 1 hysterecto and bilateral .s...a i p go--oop r e c to S per fo d. The posty opera ~ i course S and the pathology report the find gs de scribed above; there s n6 i d e n c e o f a ~c icat ion bet en t h e e n d o m e t r l a l c a v l t y a n d t h e a b d o ~ i n a i p r e g n a n c y .....
386
MARCH
1976
V O L . 13 N O . 3
CONTRACEI~FION
Case 2 D .B. s a 26 ear id g r i d a 2, p a 1 :wlth certain She s seen for pre y rlficatlon in the S Fr clsco neral spiral pr atal cl ic o n y i, 1 9 7 5 . A t t h a t tl s est teal'that h e r p r e cy s 22 s menstrual age based~ o n p h y s i c a l e inat~0n, the date "ofoquickenl ~ d ~SO g " Other f Ings cl ed a 6 c~ left ce i c a l ....~ ...a s s t ught to be a ielo a easily aud le fetai heart tones, y 21st she returned th a c iaint of not h inE f~It the fetus ve for o eks. e r e ~had ...b ..e no f dal gr th since t last visit d t h e f e t ~ l ~heart s not a ible. Sonogr rlfi fetal d se d nhe pres ce of po r s. ~y 27th she s a it ted t o t h e spltal and a urine alysis, CBC, p l a t e l e ~ co t, t h r in clottl t and set f rlno E re nor 1 1 its. iocentesis obna ed br tic id a 40 F s i n s t i i i ed i n t r a io t i C a ii y t ut cid t. No contra ions occurred with t n t y - f o u r h o u r s so a s e c o ~n~ectlon of 4 0 PGF s a istered intra~ iotically. Eight urs later her o 1 te era t s 38.1 C d cl Ical e dence of peritonitis s p~esent. A repeat iocentesls revealed 10-15 C per hi E po red field. ~ ...d .i a g sis of ~ ionltls s de d tray us penicillin and intr c k ther y s begun. Si e there had b no contractions and no cervical e f facem t o r d i i a ta t ion, t dec i sion s de n o e~p t y the ut e rus by hysteroto . The f d g s at s u r g e r y i n c l u d e d a n terior 8 x 5 cm uterus. P o s t e r i o r a n d s u p e r i o r to t h e u t e r u s s a 14 c ~ d i a ter iotlc sac c o n t a i n i n g a 1 7 0 fetus se cr -ru ~length s ° 12"....cm. .. The placenta s a t t a c h e d to t h e p o s t e r i o r s u r f a c e of t h e u t e r u s , ! e f t b'road- i ig nt ~ fa !i o p Jan. t e d o v a r y. d it i o n a l f ing s ciuded a right tubo ovarian cess. ~ total abdo al hysterecto a bilateral~salplngo-oophorect s perfo d to r ve the p i acent a d f e t u S. oT h e p o s t o p e r a t e tour se s ev t ful. ~he pat logy report confir d the find gs descr ed abo d de nstrated that the left fallopian tube s t original site o f the pregnancy. DISCUSSI T se t cases had a n er of s il clinlcai lea re8 ich should alert the ob.stetrici to t possib ity of do al preg ncy. th had r i fi inEs on pel c ex ation d did not respo to intr iotic P . addition, the first pail t had no !ntra'uter e pro c t s of' C Ceptlon On t curretages. e so gram in each case s i n t e r p r e t e d a s .... i n t r a ' u t e r e pre y th a sol pelvic ss ~ s u g g e s t i n g a l e i d i d n o t .a
MARCH
76
.
. 3
387
C
TRACE
1
in a r r g at the c o r r e c t d i a osis. It is c l e a r that a s u c c e s s f u l io c t es is a co licat ed ins t i l l a t l o n o f P G F d o e s no t a s s u r e the p r e s e n c e o f intra-uter e pre ahoy. If i n t r a i o t i c P G F a s s e r t s its e f f e c t l o c a l l y r a t h e r t by syst ic a b s o r p t i o n d redistr u t i o n ,th the i k of u t e r i n e response o u r e a s e s is r e a d i l y .... e r s t o o d ( 3 ) , ers i n o u r e eri ce 8% of the p a t i e n t s r e q u i r e a s e c o n d i n s t i l l a t i o n of F to i u c e labor. T h e r e f o r e ~ f a i l u r e of u t e r i n e r e s p o n s e to t ra-a iot d o e s no t, b y i t self ~ n e c es sar i l y i icat e i situation, w er~ w e s u g g e s t that t ~ a i i u r e of u t e r i n e r e s p o n s e t o P G F in a s s o c i a t i o n w i t h nor i findings on pelvic e nation~ d a so g r a m i n t e r p r e t e d as a s o l i d ss c o n t i g u o u s w i t h the p r e a n c y s h o u l d a l e r t the p h y s i c i a n to the p o s s illty of o m l n a l pre ahoy.
0 Co
G : wish y for s u p p l y i n g the
. Ted So e r n of T h e U p j o iD P2~ (Prostin, T h salt).
REF I. int
ES
d Sha , SD. S e c o n d - t r ester a b o r t i o n i o t i c i n j e c t i o n of p r o s t a g l a n d l n s E 2 and F2e.
-
single ncet
2 :4 7-4 8 (i 97 i) 2.
C or son, SL, B o l o ~ e s e 0 , , and rola, J. prostagl d F to i n d u c e m i d t r ester
Ob s te t C 3.
eco i ~ ~ 7 :2 7-34
tra-a ortion,
iot ic er J
(i 9 73)
ghlssl, K S a n d tray, CP. T h e f u n c t i o n of p r o s t a g l d in r e p r o d u c t i o n . O b s t e t G e c o l Su ey 2 5 - 2 8 1 - 2 9 6 (1972)
s
°4
~ AR
t976
VOL.
NO.
3
