Volume 133 Number 2
Communications in brief
fluid to penmt Its expression into the ooplasm (Fig. 5). Incubation of the ova in the three successful nuclear transfers in the pooled follicular fluid with the addition of a few drops of tubal secretion in a moist chamber to prevent evaporation at 37° C. and atmospheric oxygen tension gave rise to holoblastic cleavage into the twocell stage of blastomeres after approximately 30 hours, ieading to a definitive moruia or muiberry-iike baH of cells by the end of the third day, the stage of development \vhcn the ovum enters the uterine cavity following normal fertilization in the outer third of the fallopian tube (Fig. 6). The experiment was discontinued at this stage. There was every indication that each specimen was developing normally and could readily have been transferred in utero by the catheter technique cited in 1971. 2 These observations are being extended experimentally for further confirmation and possible refinement in technique. Patient permission was obtained for these experimental observations.
REFERENCES I. Shettles, L. B.: Ovum humanum, Munich, 1960. Urban
und Schwarzenberg. 2. Shettles, L. B.: Human blastocyst grown in vitro in ovulation cervical mucus, Nature 229: 343, 1971.
225
vaginal spotting of 3 days' duration and persistent lower abdominal pain which had been increasing in severity since its sudden onset 18 hours earlier. The patient's vital signs were stable; however, the abdomen exhibited direct and rebound tenderness. The cervix, uterus, and adnexal structures were tender, and a culdocentesis produced nonclotted blood. A celiotomy was performed and 100 c.c. of nonclotted blood were found in the peritoneal cavity. The left salpinx and ovary were covered by dense fibrous adhesions and were bound to the pelvic sidewall. The right adnexa was free of adhesions, but the an1pullary portion of lhe rig-lu salpinx was distended. A slit salpingotomy was performed and the gestation was easily removed from the tube by blunt dissection. No bleeding was observed from the implantation site. The linear salpingotomy was left open and during suturing of the incision margins, meticulous care was taken to insure hemostasis. The patient did not require transfusions and she did not receive hydrotubation. She was discharged on the fifth day of an uncomplicated, afebrile postoperative course. Eighteen days after the laparotomy she experienced sudden onset of severe abdominal pain and returned to Barnes Hospital. The initial evaluation revealed that she was afebrile and had stable vital signs. The abdomen was tender and guarded; bowel sounds were absent. The degree of abdominal tenderness precluded a satisfactory pelvic examination. During the next 2 hours, despite intravenous fluid therapy, she became hypotensive and tachycardic, with increasing abdominal distention and rigidity. A second celiotomy was performed and there were 2,000 c.c. of fresh blood and clot within the abdomen. Fresh blood was emanating from the fimbriated end of the right salpinx
Delayed hemorrhage in conservative surgery for ectopic pregnancy ROBERT W. KELLY, M.D., F.A.C.O.G. SCOTT A.
~v1ARTI1\l,
rvf.D.
RONALD C. STRICKLER, M.D., F.R.C.S.(C.), F.A.C.O.G. Department of Obstetrics and Gynecology and Division of Surgical Patlwlogy, Washington University School of Medicine, St. Louis, Missouri EcTOPIC PREGNANCY commonly causes acute hemorrhage from disruption of the primary site of implantation. Delayed hemorrhage from the implantation site following surgery to preserve the fallopian tube is rare and is documented in this report.
A 30-year-old black woman, gravida 3, para 1, therapeutic abortus 2, whose last pregnancy was in 1973, had not used contraception for 2 years. Her menstrual cycle was regular and occurred every 26 days. She denied previous pelvic infections. In September, 1977, 34 days after her last normal menstrual flow, she was admitted to Barnes Hospital with a clinical diagnosis of ectopic pregnancy. She complained of Reprint requests: Ronald C. Strickler, M.D., Department of Obst~trics and Gynecology, Washington University School of Medicine, 4911 Barnes Hospital Plaza, St. Louis, Missouri 63110. 0002-9378/79/020225+02$00.20/0
©
1979 The C. V. Mosby Co.
and multiple pulsating bleeding points were observed in the area of the previous gestational implantation site. A right salpingectomy and cornual resection were performed. No other source for the intraperitoneal bleeding was found. Other than requiring 2,000 c. c. of whole blood during the procedure and experiencing paralytic ileus during the 4 days after operation, her hospitalization was uncomplicated. She was discharged on the tenth postoperative day and was completely well at a 3 month follow-up visit. Serum levels of chorionic gonadotropin ,8-subunit commenced on the day of hospital discharge (a pre-
caution against the unlikely event that this was an early trophoblast neoplasia) have remained normal. Microscopic examination of the excised fallopian tube revealed intraluminal hemorrhage and fibrinous exudate. There were areas of decidual change in the stroma and interstitial infiltrates of neutrophiles, lymphocytes, and plasma cells were observed. Residual cytotrophoblast and syncytiotrophoblast, but no villi, were found infiltrating the wall of the salpinx and invading blood vessels (Fig. 1). The concepts of management of ectopic pregnancy have progressed from unilateral salpingo-oophorectomy to salpingectomy alone and now to procedures which, in selected cases, preserve reproductive function. When a patient's clinical state permits, and selective removal of the ectopic gestation is possible, with hope that a functional fallopian tube may result, we preserve reproductive capacity. In our case, hen1orthage fron1 the implantation site in the fallopian tube occurred 18 days after the initial salpingotomy. This complication of fallopian tube sal-
226
.J anuarv 15. 1979 Am . J. Obstet. Gvnecol.
Communications in brief
Fig. I. Vascular invasion by cytotrophoblast. Intraluminal cytotrophoblast is present in a vein in the wall of the salpinx . In the adjacent interstitial tissues are infiltrates of inflammatory cells. ( Hematoxylin and eosin. x 150.)
vage procedures has not been described in the English literature of the past 20 years. Ploman and WickseiP and Rosenblum, Dowling, and Barnes, 2 whose combined experience is 149 conservative operations, advised ligation of vessels in the mesosalpinx adjacent to the implantation in order to secure hemostasis. The source of the delayed hemorrhage in this case was demonstrated to be associated with vascular invasion by persistent trophoblast in the implantation site in the salpinx. The operative management of this patient did not include a prophylactic suture in the mesosalpinx to interrupt the vascular supply to the implantation site. Such a maneuver would probably have prevented the delayed hemorrhage. We therefore recommend this precautionary measure in conservative surgical procedures in cases of ectopic gestation.
REFERENCES I. Ploman, L., and Wicksell, F.: Fertility after conservative surgery in tubal pregnancy, Acta Obstet. Gynecol. Scand . 39:143, 1960. 2. Rosenblum, J. M., Dowling, R. W., and Barnes , A. C.: Treatment of tubal pregnancy, AM . J. 0BSTET. GYNECOL. 80:274 , 1960.
External pneumatic compression for prevention of deep venous thrombosis and pulmonary emboli ANN B . BARNES , M . D.
Vincent Memorial Hospital (Gynecological Service of the Massachusetts General Hospital) , Boston, Massachusetts
RECENT EXPERIENCE has Jed to the recognition of a need for control trials in obstetrics and gynecology to evaluate external pneumatic compression (EPC) for the prevention of deep-vein thrombosis and pulmonary emboli. A 21-yea r-old patient with mesangial-type glomerulonephritis, in her fourth pregnancy, was admitted in the twentieth week of pregnancy for hypertension , vaginal staining, abdominal cramping, edema, and a rising serum creatinine despite H ydrodiuril and Aldomet thera py . Her blood pressure ra nged from 140/90 mm. Hg despite increasing Hydrodiuril and Aldomet. At 20 weeks, with vaginal staining and crampy pains, she was placed on bed rest. Ultrasound Reprint requests: Ann B. Barnes, M.D., Vincent Memorial Hospital , 32 Fruit St. , Boston, Massachusetts 02114. 0002-9378/79/ 020226+02$00.20/0
©
1979 The C. V. Mosby Co.
Communications in brief
fluid to penmt Its expression into the ooplasm (Fig. 5). Incubation of the ova in the three successful nuclear transfers in the pooled follicular fluid with the addition of a few drops of tubal secretion in a moist chamber to prevent evaporation at 37° C. and atmospheric oxygen tension gave rise to holoblastic cleavage into the twocell stage of blastomeres after approximately 30 hours, ieading to a definitive moruia or muiberry-iike baH of cells by the end of the third day, the stage of development \vhcn the ovum enters the uterine cavity following normal fertilization in the outer third of the fallopian tube (Fig. 6). The experiment was discontinued at this stage. There was every indication that each specimen was developing normally and could readily have been transferred in utero by the catheter technique cited in 1971. 2 These observations are being extended experimentally for further confirmation and possible refinement in technique. Patient permission was obtained for these experimental observations.
REFERENCES I. Shettles, L. B.: Ovum humanum, Munich, 1960. Urban
und Schwarzenberg. 2. Shettles, L. B.: Human blastocyst grown in vitro in ovulation cervical mucus, Nature 229: 343, 1971.
225
vaginal spotting of 3 days' duration and persistent lower abdominal pain which had been increasing in severity since its sudden onset 18 hours earlier. The patient's vital signs were stable; however, the abdomen exhibited direct and rebound tenderness. The cervix, uterus, and adnexal structures were tender, and a culdocentesis produced nonclotted blood. A celiotomy was performed and 100 c.c. of nonclotted blood were found in the peritoneal cavity. The left salpinx and ovary were covered by dense fibrous adhesions and were bound to the pelvic sidewall. The right adnexa was free of adhesions, but the an1pullary portion of lhe rig-lu salpinx was distended. A slit salpingotomy was performed and the gestation was easily removed from the tube by blunt dissection. No bleeding was observed from the implantation site. The linear salpingotomy was left open and during suturing of the incision margins, meticulous care was taken to insure hemostasis. The patient did not require transfusions and she did not receive hydrotubation. She was discharged on the fifth day of an uncomplicated, afebrile postoperative course. Eighteen days after the laparotomy she experienced sudden onset of severe abdominal pain and returned to Barnes Hospital. The initial evaluation revealed that she was afebrile and had stable vital signs. The abdomen was tender and guarded; bowel sounds were absent. The degree of abdominal tenderness precluded a satisfactory pelvic examination. During the next 2 hours, despite intravenous fluid therapy, she became hypotensive and tachycardic, with increasing abdominal distention and rigidity. A second celiotomy was performed and there were 2,000 c.c. of fresh blood and clot within the abdomen. Fresh blood was emanating from the fimbriated end of the right salpinx
Delayed hemorrhage in conservative surgery for ectopic pregnancy ROBERT W. KELLY, M.D., F.A.C.O.G. SCOTT A.
~v1ARTI1\l,
rvf.D.
RONALD C. STRICKLER, M.D., F.R.C.S.(C.), F.A.C.O.G. Department of Obstetrics and Gynecology and Division of Surgical Patlwlogy, Washington University School of Medicine, St. Louis, Missouri EcTOPIC PREGNANCY commonly causes acute hemorrhage from disruption of the primary site of implantation. Delayed hemorrhage from the implantation site following surgery to preserve the fallopian tube is rare and is documented in this report.
A 30-year-old black woman, gravida 3, para 1, therapeutic abortus 2, whose last pregnancy was in 1973, had not used contraception for 2 years. Her menstrual cycle was regular and occurred every 26 days. She denied previous pelvic infections. In September, 1977, 34 days after her last normal menstrual flow, she was admitted to Barnes Hospital with a clinical diagnosis of ectopic pregnancy. She complained of Reprint requests: Ronald C. Strickler, M.D., Department of Obst~trics and Gynecology, Washington University School of Medicine, 4911 Barnes Hospital Plaza, St. Louis, Missouri 63110. 0002-9378/79/020225+02$00.20/0
©
1979 The C. V. Mosby Co.
and multiple pulsating bleeding points were observed in the area of the previous gestational implantation site. A right salpingectomy and cornual resection were performed. No other source for the intraperitoneal bleeding was found. Other than requiring 2,000 c. c. of whole blood during the procedure and experiencing paralytic ileus during the 4 days after operation, her hospitalization was uncomplicated. She was discharged on the tenth postoperative day and was completely well at a 3 month follow-up visit. Serum levels of chorionic gonadotropin ,8-subunit commenced on the day of hospital discharge (a pre-
caution against the unlikely event that this was an early trophoblast neoplasia) have remained normal. Microscopic examination of the excised fallopian tube revealed intraluminal hemorrhage and fibrinous exudate. There were areas of decidual change in the stroma and interstitial infiltrates of neutrophiles, lymphocytes, and plasma cells were observed. Residual cytotrophoblast and syncytiotrophoblast, but no villi, were found infiltrating the wall of the salpinx and invading blood vessels (Fig. 1). The concepts of management of ectopic pregnancy have progressed from unilateral salpingo-oophorectomy to salpingectomy alone and now to procedures which, in selected cases, preserve reproductive function. When a patient's clinical state permits, and selective removal of the ectopic gestation is possible, with hope that a functional fallopian tube may result, we preserve reproductive capacity. In our case, hen1orthage fron1 the implantation site in the fallopian tube occurred 18 days after the initial salpingotomy. This complication of fallopian tube sal-
226
.J anuarv 15. 1979 Am . J. Obstet. Gvnecol.
Communications in brief
Fig. I. Vascular invasion by cytotrophoblast. Intraluminal cytotrophoblast is present in a vein in the wall of the salpinx . In the adjacent interstitial tissues are infiltrates of inflammatory cells. ( Hematoxylin and eosin. x 150.)
vage procedures has not been described in the English literature of the past 20 years. Ploman and WickseiP and Rosenblum, Dowling, and Barnes, 2 whose combined experience is 149 conservative operations, advised ligation of vessels in the mesosalpinx adjacent to the implantation in order to secure hemostasis. The source of the delayed hemorrhage in this case was demonstrated to be associated with vascular invasion by persistent trophoblast in the implantation site in the salpinx. The operative management of this patient did not include a prophylactic suture in the mesosalpinx to interrupt the vascular supply to the implantation site. Such a maneuver would probably have prevented the delayed hemorrhage. We therefore recommend this precautionary measure in conservative surgical procedures in cases of ectopic gestation.
REFERENCES I. Ploman, L., and Wicksell, F.: Fertility after conservative surgery in tubal pregnancy, Acta Obstet. Gynecol. Scand . 39:143, 1960. 2. Rosenblum, J. M., Dowling, R. W., and Barnes , A. C.: Treatment of tubal pregnancy, AM . J. 0BSTET. GYNECOL. 80:274 , 1960.
External pneumatic compression for prevention of deep venous thrombosis and pulmonary emboli ANN B . BARNES , M . D.
Vincent Memorial Hospital (Gynecological Service of the Massachusetts General Hospital) , Boston, Massachusetts
RECENT EXPERIENCE has Jed to the recognition of a need for control trials in obstetrics and gynecology to evaluate external pneumatic compression (EPC) for the prevention of deep-vein thrombosis and pulmonary emboli. A 21-yea r-old patient with mesangial-type glomerulonephritis, in her fourth pregnancy, was admitted in the twentieth week of pregnancy for hypertension , vaginal staining, abdominal cramping, edema, and a rising serum creatinine despite H ydrodiuril and Aldomet thera py . Her blood pressure ra nged from 140/90 mm. Hg despite increasing Hydrodiuril and Aldomet. At 20 weeks, with vaginal staining and crampy pains, she was placed on bed rest. Ultrasound Reprint requests: Ann B. Barnes, M.D., Vincent Memorial Hospital , 32 Fruit St. , Boston, Massachusetts 02114. 0002-9378/79/ 020226+02$00.20/0
©
1979 The C. V. Mosby Co.
