280
Communications
January 15, 197.5 Am. J. Obstct. Gynecol
in brief
plastic foreign object might affect the barrier amniotic fluid and the maternal circulation is scope of this case presentation. However, it appropriate to comment on a quirk of diagnostic cation which can lead to the conjecture that maternal lationship
deaths may but remain
have involved unknown to
this the
separating outside the does seem classifieven more
intriguing medically
rein-
quisitive person. It is a fact that the standard reference for classification of diseases used by hospitals and agencies dealing with the collection of health data does not include adequate classification numbers for relating IUD’s to associated complications.’ This omission persists despite the manufacture of about 30 million IUD’s by American companies alone during the past decade for domestic and foreign sales.” What proportion of the estimated 3 million American women utilizing IUD contraception will experience major complications is not known. But the lack of coding precludes anything but a guess of the number. Because of this coding oversight, it has been by virtual accident, then, that mention of IUD’s associated with pregnancy terminating in amniotic fluid embolism death
Fig. 1. Lateral
abdominal x-ray of a 29-year-old woman at about 42 weeks’ gestation with an in situ Lippes Loop “B.” The patient sustained amniotic fluid embolism during labor, was delivered of a stillborn infant and the placenta with the IUD, and then died from cardiopulmonary arrest.
has been made. No literature reviews of amniotic fluid embolism of which I am aware have been concerned with the contraceptive practices or failures of the women who die from amniotic fluid embolism. It is hoped that the reporting of this case and the discovery in the medical literature of 3 other cases with similar association might prompt the recollection of physicians who have been involved in the case of patients who
pulmonary arrest resulting in the death of the patient occurred a short time after delivery. Autopsy findings were those of severe pulmonary atelectasis associated with massive amniotic debris accumulations throughout the vasculature of the lungs and within the alveolar spaces. In a report concluded in January, 1968, survey of members of the American College tricians and Gynecologists, Scott2 documented
based on a of Obstethe deaths
of 10 women which were in some way related to IUD’s. In 2 of these 10 deaths, the cause of death was amniotic fluid embolism (Cases 7 and 9). Although both of these cases involved IUD’s which coexisted with pregnancy, Scott claimed as “doubtful” any relationship between the IUD’s and the amniotic fluid embolisms. McLeod:+ reported the unusual incidence of fatal amniotic fluid embolisms in Dade County, Florida, noting that particular cause of death in 6 of the 9 maternal deaths in the county in 1970. One of these 6 amniotic fluid embolism deaths occurred in association with an in situ IUD. McLeod did not propose that that fact demonstrated any relationship but mentioned it in passing as an aspect of the patient’s history. The report of an additional case of maternal death from amniotic fluid embolism in pregnancy with an in situ IUD does raise the question of a possible association. A discussion of the possible mechanisms by which a
sustained
this
rare
complication
of pregnancy.
REFERENCES
1. 2.
3. 4.
5.
Courtney, L. D.: Obstet. Gynecol. Survey 29: 169, 1974. Gynecol. 31: 322, 1968. Scott, R. B.: Obstet. McLeod. .4. G. W.: AM. T. OBSTET. GYNECOL. 113: 1103, 1972. United States Department of Health, Education, and Welfare: International Classification of Diseases (I. C. D. A.), Eighth Revision, Public Health Service Publication No. 1693. Washineton, D. C., 1969, United States Government Printing-O&e. Office of Medical Devices, Food and Drug Administration, Rockville, Maryland : Personal communication.
Burkitt’s lymphoma: GERALD
WILSON
Department Clinic-St.
of Obstetrics
Luke’s
Case report HUNTER,
and Gynecology, Hospitals, Fargo, North
M.D. Fargo Dakota
lymphoma ocB u R K I T T ’ s T u hr 0 R is a malignant curring mostly in children, mainly in certain parts of Africa. However, cases have been reported all over the world in an increasing number of adults. Burkitt* sugReprint requests: Clinic, 737 Broadway,
Dr. Gerald Wilson Hunter, Fargo, North Dakota 58102.
Fargo
Volume Number
121 2
gested an insect While certainly
Communications
that
the
disease
could be caused by a virus with
vector. the disease is becoming more common, a rarity in most of our country. Dr.
it is still Paul H.
Levine? has stated that “American” and “African” Burkitt’s lymphomas differ. He published a diagram which indicated that the distribution of American cases was mainly along the Atlantic, Gulf, and Pacific seaboards with a scattering of cases throughout the eastern central states. There have been 97 cases confirmed, and 42 are presently being evaluated. The Fargo Clinic-St. Luke’s Hospitals medical complex receives referred patients from all over the state. The one under consideration was sent to us 2 years ago. She was first seen by her referring doctor and complained of acute abdominal pain of 10 hours’ duration. The pain had localized in the left lower quadrant and had become increasingly more severe the past 2 hours. She said she had been flowing for 5 days but was unsure of the data of her previous period. She thought she might have missed one. She was 31 years old and had 7 children and 2 spontaneous abortions. Her menstrual periods began at age 13, but they had never been regular. The examination disclosed acute abdominal symptoms with marked tenderness and rigidity in the left lower quadrant. Pelvic examination revealed the uterus to be of normal size. A mass about 5 cm. in diameter was found in the left adnexal area. A diagnosis of ectopic pregnancy was made, and she was operated upon soon after admission to the hospital. Preoperative laboratory findings showed no elevation of the white blood cell count. However, she did have some degree of anemia. The hemoglobin was 10 Gm., and the blood type was Rh negative (B). The doctor gave her 1 U. of blood. When the abdomen was opened, free blood was encountered. There was a mass in the left adnexal area which involved the cornu of the uterus and the tube. No tissue was removed from this side, but blood clots were removed and hemostasis was carried out. When the right adnexa was examined, a similar but smaller mass was found in the same relative position. This was the right ovary. There was no bleeding from this mass. It was removed along with the attached tissue that came away simultaneously. The original pathologic report on this tissue was granulosa cell tumor. She was then referred to our hospital where a pathologic diagnosis of stromal sarcoma was made. Physical examination on admission disclosed a firm mass rising out of the pelvis and extending half-way to the umbilicus. The preoperative studies were as follows: Chest x-ray, negative; hemoglobin, 9.6 Gm.; hematocrit, 27.9 vol. per cent; erythrocyte sedimentation rate, 32; white blood cell count, 5,600; differential blood count, not remarkable. The 12 panel electrolyte studies were all normal, including serum glutamic oxalacetic transaminase which was only 15 U. Weight was 132 pounds. Repeat celiotomy was performed. The tumor had ruptured through the uterine wall, and there were implants over the lateral pelvic walls. The right adnexa had been removed at the time of the recent operation. Total hysterectomy, left salpingo-oophorectomy, and removal of as much of the tumor material as possible were done. There was a rather large area of implantation on the bladder. The tumor had infiltrated a large portion of the wall so it was impossible to remove this entirely without excising the bladder. Implants on the intestines were removed. Exploration of the upper abdomen showed no evidence of
in brief
281
metastatic lesions of the liver. While we felt that we had not removed all minute metastases, we excised as much of the tumor as possible. We then distributed 100 mg. of thio-tepa over the posterior cul-de-sac area in the peritoneum. The slides had been sent to Dr. J. Donald Woodruff of the Johns Hopkins Medical School for review, and he reported that we were dealing with Burkitt’s lymphoma. He had conferred with Dr. Vincent DeVita of the National Health Institute who concurred in the diagnosis. She was given cyclophosphamide, 200 mg. daily intravenously for 9 days.” The patient did remarkably well postoperatively and was discharged on the ninth postoperative day with instructions to return to her referring doctor. He continued to give her cyclophosphamide, 2000 mg. intravenously in normal saline each month for the next 6 months. The white blood cell count never went below 2,000. She tolerated this therapy well and complained only of a short period of backache and slight nausea followin, v each instance of medication. We checked samples of the patient’s blood for Epstein Barr virus allergens and found them present in a high dilution. Burkitt’s cases showed similar findings. I am aware this finding is not specific for Burkitt’s tumors, but all Burkitt’s lymphomas are positive for the test. The patient was seen one year following therapy for further studies. These were all essentially negative. Physical examination was unremarkable. She stated that she had lost all her hair following the chemotherapy, but it had grown in again. Bimanual examination disclosed no sign of residual tumor. The radiologic studies revealed a negative pelvic lymphangiogram. Twelve cubic centimeters of contrast medium was injected bilaterally, and the nodes appeared to be of normal size and showed no evidence of abnormal replacement or displacement. The intravenous pyelogram showed good bilateral renal function without abnormal displacement of the kidneys and normal caliceal pattern. There was no evidence of ureteral displacement. A brain scan and chest x-ray were negative. Vaginal smears showed an atrophic pattern despite the fact that the mucosa was pink and moist. Studies showed 100 per cent intermediate cells. She stated that she had not had hot flashes. She was not receiving estrogens. Her sex life was excellent; in fact, she commented that it was better than before the operation since she no longer feared another pregnancy. The fasting electrolyte studies were all normal. Serum glutamic oxalacetic transaminase was 6 U. Blood counts were normal; hemoglobin, 13.3 Gm., hematocrit, 39.1 vol. per cent; erythrocyte sedimentation rate, 8. A spinal tap was negative. The patient is alive and well today. Burkitt’s
lymphorna
is one
of several
rapidly
growing
tumors that may yield to chemotherapy. Cyclophosphamide and methotrexate are the medications recommended. We chose the former and administered it in the manner mentioned above.
I am grateful to Dr. Dakota, for the referral
Robert Gammel of this patient.
of Kenmare,
REFERENCES
1. 2. 3.
Burkitt, Levine, Krakoff,
D. P.: J. Natl. Cancer Inst. 42: 18, 1969. P. H.: J. A. M. A. 225: 15, 1973. I. H.: 23: 209, 1973.
North
Communications
January 15, 197.5 Am. J. Obstct. Gynecol
in brief
plastic foreign object might affect the barrier amniotic fluid and the maternal circulation is scope of this case presentation. However, it appropriate to comment on a quirk of diagnostic cation which can lead to the conjecture that maternal lationship
deaths may but remain
have involved unknown to
this the
separating outside the does seem classifieven more
intriguing medically
rein-
quisitive person. It is a fact that the standard reference for classification of diseases used by hospitals and agencies dealing with the collection of health data does not include adequate classification numbers for relating IUD’s to associated complications.’ This omission persists despite the manufacture of about 30 million IUD’s by American companies alone during the past decade for domestic and foreign sales.” What proportion of the estimated 3 million American women utilizing IUD contraception will experience major complications is not known. But the lack of coding precludes anything but a guess of the number. Because of this coding oversight, it has been by virtual accident, then, that mention of IUD’s associated with pregnancy terminating in amniotic fluid embolism death
Fig. 1. Lateral
abdominal x-ray of a 29-year-old woman at about 42 weeks’ gestation with an in situ Lippes Loop “B.” The patient sustained amniotic fluid embolism during labor, was delivered of a stillborn infant and the placenta with the IUD, and then died from cardiopulmonary arrest.
has been made. No literature reviews of amniotic fluid embolism of which I am aware have been concerned with the contraceptive practices or failures of the women who die from amniotic fluid embolism. It is hoped that the reporting of this case and the discovery in the medical literature of 3 other cases with similar association might prompt the recollection of physicians who have been involved in the case of patients who
pulmonary arrest resulting in the death of the patient occurred a short time after delivery. Autopsy findings were those of severe pulmonary atelectasis associated with massive amniotic debris accumulations throughout the vasculature of the lungs and within the alveolar spaces. In a report concluded in January, 1968, survey of members of the American College tricians and Gynecologists, Scott2 documented
based on a of Obstethe deaths
of 10 women which were in some way related to IUD’s. In 2 of these 10 deaths, the cause of death was amniotic fluid embolism (Cases 7 and 9). Although both of these cases involved IUD’s which coexisted with pregnancy, Scott claimed as “doubtful” any relationship between the IUD’s and the amniotic fluid embolisms. McLeod:+ reported the unusual incidence of fatal amniotic fluid embolisms in Dade County, Florida, noting that particular cause of death in 6 of the 9 maternal deaths in the county in 1970. One of these 6 amniotic fluid embolism deaths occurred in association with an in situ IUD. McLeod did not propose that that fact demonstrated any relationship but mentioned it in passing as an aspect of the patient’s history. The report of an additional case of maternal death from amniotic fluid embolism in pregnancy with an in situ IUD does raise the question of a possible association. A discussion of the possible mechanisms by which a
sustained
this
rare
complication
of pregnancy.
REFERENCES
1. 2.
3. 4.
5.
Courtney, L. D.: Obstet. Gynecol. Survey 29: 169, 1974. Gynecol. 31: 322, 1968. Scott, R. B.: Obstet. McLeod. .4. G. W.: AM. T. OBSTET. GYNECOL. 113: 1103, 1972. United States Department of Health, Education, and Welfare: International Classification of Diseases (I. C. D. A.), Eighth Revision, Public Health Service Publication No. 1693. Washineton, D. C., 1969, United States Government Printing-O&e. Office of Medical Devices, Food and Drug Administration, Rockville, Maryland : Personal communication.
Burkitt’s lymphoma: GERALD
WILSON
Department Clinic-St.
of Obstetrics
Luke’s
Case report HUNTER,
and Gynecology, Hospitals, Fargo, North
M.D. Fargo Dakota
lymphoma ocB u R K I T T ’ s T u hr 0 R is a malignant curring mostly in children, mainly in certain parts of Africa. However, cases have been reported all over the world in an increasing number of adults. Burkitt* sugReprint requests: Clinic, 737 Broadway,
Dr. Gerald Wilson Hunter, Fargo, North Dakota 58102.
Fargo
Volume Number
121 2
gested an insect While certainly
Communications
that
the
disease
could be caused by a virus with
vector. the disease is becoming more common, a rarity in most of our country. Dr.
it is still Paul H.
Levine? has stated that “American” and “African” Burkitt’s lymphomas differ. He published a diagram which indicated that the distribution of American cases was mainly along the Atlantic, Gulf, and Pacific seaboards with a scattering of cases throughout the eastern central states. There have been 97 cases confirmed, and 42 are presently being evaluated. The Fargo Clinic-St. Luke’s Hospitals medical complex receives referred patients from all over the state. The one under consideration was sent to us 2 years ago. She was first seen by her referring doctor and complained of acute abdominal pain of 10 hours’ duration. The pain had localized in the left lower quadrant and had become increasingly more severe the past 2 hours. She said she had been flowing for 5 days but was unsure of the data of her previous period. She thought she might have missed one. She was 31 years old and had 7 children and 2 spontaneous abortions. Her menstrual periods began at age 13, but they had never been regular. The examination disclosed acute abdominal symptoms with marked tenderness and rigidity in the left lower quadrant. Pelvic examination revealed the uterus to be of normal size. A mass about 5 cm. in diameter was found in the left adnexal area. A diagnosis of ectopic pregnancy was made, and she was operated upon soon after admission to the hospital. Preoperative laboratory findings showed no elevation of the white blood cell count. However, she did have some degree of anemia. The hemoglobin was 10 Gm., and the blood type was Rh negative (B). The doctor gave her 1 U. of blood. When the abdomen was opened, free blood was encountered. There was a mass in the left adnexal area which involved the cornu of the uterus and the tube. No tissue was removed from this side, but blood clots were removed and hemostasis was carried out. When the right adnexa was examined, a similar but smaller mass was found in the same relative position. This was the right ovary. There was no bleeding from this mass. It was removed along with the attached tissue that came away simultaneously. The original pathologic report on this tissue was granulosa cell tumor. She was then referred to our hospital where a pathologic diagnosis of stromal sarcoma was made. Physical examination on admission disclosed a firm mass rising out of the pelvis and extending half-way to the umbilicus. The preoperative studies were as follows: Chest x-ray, negative; hemoglobin, 9.6 Gm.; hematocrit, 27.9 vol. per cent; erythrocyte sedimentation rate, 32; white blood cell count, 5,600; differential blood count, not remarkable. The 12 panel electrolyte studies were all normal, including serum glutamic oxalacetic transaminase which was only 15 U. Weight was 132 pounds. Repeat celiotomy was performed. The tumor had ruptured through the uterine wall, and there were implants over the lateral pelvic walls. The right adnexa had been removed at the time of the recent operation. Total hysterectomy, left salpingo-oophorectomy, and removal of as much of the tumor material as possible were done. There was a rather large area of implantation on the bladder. The tumor had infiltrated a large portion of the wall so it was impossible to remove this entirely without excising the bladder. Implants on the intestines were removed. Exploration of the upper abdomen showed no evidence of
in brief
281
metastatic lesions of the liver. While we felt that we had not removed all minute metastases, we excised as much of the tumor as possible. We then distributed 100 mg. of thio-tepa over the posterior cul-de-sac area in the peritoneum. The slides had been sent to Dr. J. Donald Woodruff of the Johns Hopkins Medical School for review, and he reported that we were dealing with Burkitt’s lymphoma. He had conferred with Dr. Vincent DeVita of the National Health Institute who concurred in the diagnosis. She was given cyclophosphamide, 200 mg. daily intravenously for 9 days.” The patient did remarkably well postoperatively and was discharged on the ninth postoperative day with instructions to return to her referring doctor. He continued to give her cyclophosphamide, 2000 mg. intravenously in normal saline each month for the next 6 months. The white blood cell count never went below 2,000. She tolerated this therapy well and complained only of a short period of backache and slight nausea followin, v each instance of medication. We checked samples of the patient’s blood for Epstein Barr virus allergens and found them present in a high dilution. Burkitt’s cases showed similar findings. I am aware this finding is not specific for Burkitt’s tumors, but all Burkitt’s lymphomas are positive for the test. The patient was seen one year following therapy for further studies. These were all essentially negative. Physical examination was unremarkable. She stated that she had lost all her hair following the chemotherapy, but it had grown in again. Bimanual examination disclosed no sign of residual tumor. The radiologic studies revealed a negative pelvic lymphangiogram. Twelve cubic centimeters of contrast medium was injected bilaterally, and the nodes appeared to be of normal size and showed no evidence of abnormal replacement or displacement. The intravenous pyelogram showed good bilateral renal function without abnormal displacement of the kidneys and normal caliceal pattern. There was no evidence of ureteral displacement. A brain scan and chest x-ray were negative. Vaginal smears showed an atrophic pattern despite the fact that the mucosa was pink and moist. Studies showed 100 per cent intermediate cells. She stated that she had not had hot flashes. She was not receiving estrogens. Her sex life was excellent; in fact, she commented that it was better than before the operation since she no longer feared another pregnancy. The fasting electrolyte studies were all normal. Serum glutamic oxalacetic transaminase was 6 U. Blood counts were normal; hemoglobin, 13.3 Gm., hematocrit, 39.1 vol. per cent; erythrocyte sedimentation rate, 8. A spinal tap was negative. The patient is alive and well today. Burkitt’s
lymphorna
is one
of several
rapidly
growing
tumors that may yield to chemotherapy. Cyclophosphamide and methotrexate are the medications recommended. We chose the former and administered it in the manner mentioned above.
I am grateful to Dr. Dakota, for the referral
Robert Gammel of this patient.
of Kenmare,
REFERENCES
1. 2. 3.
Burkitt, Levine, Krakoff,
D. P.: J. Natl. Cancer Inst. 42: 18, 1969. P. H.: J. A. M. A. 225: 15, 1973. I. H.: 23: 209, 1973.
North
