342
Communications
October
in brief
provement in ventilation is achieved with a 5 mg. oral dose of terbutaline or 0.25 mg. subcutaneously. With 10 mg. orally, there is little further improvement in ventilation, as measured by forced expiratory volume, and significant cardiovascular effects are seen. Moreover, at the 10 mg. dose level, the effect lasts six to seven hours. A single, massive overdose of terbutaline has been inadvertently administered in at least one patient, an elderly woman with asthma who was given 2.5 mg. subcutaneously instead of 0.25 mg. She experienced extreme tachycardia and myocardial &hernia but did not develop pulmonary edema.2 Our patient differed in that she received dexamethasone as well, she was pregnant, and she received more prolonged treatment. Glucocorticoids have been used clinically in massive doses in sepsis and shock and are thought to stabilize lysosome membranes and decrease capillary permeability. Thus, it is unlikely that dexamethasone contributed to the pulmonary edema seen in our patient. Terbutaline and related beta-2-adrenergic drugs are frequently used in combination with glucocorticoids in the management of asthma and do not appear to have caused pulmonary edema. In normal pregnancy, cardiac output increases 30 to 40 per cent. Red cell mass and plasma volume increase 20 to 40 per cent (more in twin pregnancies). Cardiac output increases further with each contraction during labor
and
following
fetal
expulsion,
though
these
changes are less marked if the supine position is avoided. The most likely explanation for the pulmonary edema of our patient is prolonged exposure to a moderately high dose of the adrenergic drug superimposed on the hypervolemic and hyperdynamic cardiovascular status of the laboring pregnant woman. REFERENCES
1. Ersoz, N., and Finestone, S. C.: Adrenaline induced pulmonary edema and its treatment: a report of two cases, Br. J. Anaesth. 43: 709, 1971. 2. Lawyer, C., and Pond, A.: Problems with terbutaiine, N. Engl. J. Med. 296: 821, 1977.
Fetal skull fracture from an apparently trivial motor vehicle accident DAVID C. CUMMING, FRANCES D. WREN, Department and Foothills
FETAL nificant
of Obstetrics Hosp&xl,
M.B., M.B.
and Gynecobgy, Calgary, Alberta,
M.R.C.O.G.
University Canada
of Calgary
LOSS DUE TO TRAUMA usually follows sigmaternal trauma. This case report describes
Reprint requests: Dr. D. C. Gumming, Foothills Hospital, 1403 29th St. N.W., Calgary, Alberta, Canada T2N 2T8. OOOZ-9378/78/190342+02$00.20/O
1, 1978
Am. J. Ohstet. Gynecol.
0 1978 The C. V. Mosby Co
fetal skull fractures and intrauterine apparently trivial maternal injuries motor vehicle accident.
following sustained in a
death
A 22-year-old native Indian woman in the thirty-seventh week of her first pregnancy came to the Emergency Department following a motor vehicle accident on May 5, 1977. She had been the driver of a vehicle that she said “slid into a ditch.” She was not wearing a seat belt. Four passengers in the car suffered only minor bruising. The patient appeared to be intoxicated, with slurred speech, incoordination, and an odor of alcohol. The patient complained of a painful ankle and pain and minor bruising of the left side of the face and forehead. There was no loss of consciousness and no complaint of injury to the abdomen. A roentgenogram demonstrated a crack fracture of the lateral malleolus and a chip fracture of the medial talus with no fracture of the face or skull. Examination of the abdomen revealed IX) external bruising or tenderness. The uterine size was compatible with calculated dates of gestation. The lie was longitudinal with a cephalic presentation. Fetal movement was palpable and the fetal heart tones were normal. Following treatment for the ankle the patient was discharged. On the following day the patient went into labor and was admitted to the delivery unit. Abdominal palpation confirmed the findings of the previous day, again with no abdominal bruising or tenderness. However, no fetal heartbeat was heard. Low-forceps delivery of a stillborn male infant weighing 3,650 grams terminated a brief labor. The maternal surface of tbe placenta demonstrated multiple, small, well-defined areas of hemorrhage. Postmortem examination of the fetus revealed parietal bone fractures, tentorial tears, and subdural hemorrhages bilaterally. The placenta weighed 510 grams with multiple, small, recent placental infarcts. Microscopic examination confirmed the infarcts and showed the presence of a large chorioangioma clearly demarcated from the surrounding normal tissue.
It is unlikely during travel in a modern North American vehicle that major trauma will occur to an occupant in the absence of considerable structural damage to that vehicle.’ The vehicle involved in our case suffered minimal damage while its occupants other than the driver merely had some bruising. Fetal loss in a motor vehicle accident is most likely to be caused first by death of the mother and second by placental separation. The latter may be due to direct trauma or the shearing stresses engendered in the deceleration process. Here shearing forces were probably the cause of the placental changes described although their extent was not sufficient to cause fetal death, The finding of a chorioangioma is incidental, occurring in about 1 per cent of pregnancies. There is no evidence linking it with the changes found. Direct trauma to the fetus as a cause of death is much less common. Fractured skull as a result of a motor vehicle accident is usually associated with a fracture of the maternal pelvis.’ Crosby2 described a fracture due to crushing of the fetal skull between the seat belt buckle and the maternal pelvic. The mechanism of skull fracture in our case is not clearly established as
Communications
Volume 132 Number3
there was no evidence of local trauma to the abdomen of the mother. The most likely explanation is that the fetal head was crushed between the steering wheel rim and the maternal pelvis. This could occur without leaving maternal bruising if the factor involved was a gradually increasing pressure rather than a sudden striking of the fixed object. Hence it would be compatible with the patient’s description of the accident, where the vehicle was described as “sliding into the ditch.” The possibility that apparently minor trauma such as this coexists with major fetal injury raises questions in the management of these cases. In most cases in our hospital patients are admitted for observation but this is frequently because of the accompanying injury rather than the prospect of fetal problems. It is difficult to see a happier outcome for this patient’s pregnancy regardless of management although in retrospect if the diagnosis had been made prior to death urgent abdominal delivery might have been suitable. However, emergency room physicians must be aware of the potential for fetal loss by direct trauma and by separation from shearing stresses and be prepared to admit patients to the hospital. REFERENCES 1. Crosby, W. M.: Trauma during pregnancy: fetal injury, Obstet. Gynecol. Surv. 29: 683, 2. Crosby, W. M.: Pathology of obstetric injuries automobile accident victims, in Brinkhous, Accident Pathology, Washington, D. C., States Government Printing Office, p. 204.
maternal and 1974. in pregnant K. M., editor: 1970, United
Complication of abortion performed with a plastic suction curet: Intrauterine loss of the curet tip THOMAS
W.
THEODORE
McELIN, M.
GIESE,
M.D.,
M.S.
M.D.
Department of Obstetrics and Gynecology, McGaw Medical Cater, Northwestern Univenity, Chicago, Illinois, and Evanston Hospital, Evanston, Illinois THE LEGALIZATION OF ABORTION in the United States has resulted in many reports about equipment, techniques, and complications of first-trimester pregnancy termination. This paper presents an unusual complication of suction curettage-the breakage of the tip of the suction curet-and, to the best of our knowledge, a previously unrecorded complication. Guidelines for expediting diagnosis and management are suggested. requests: Dr. Thomas W. McElin, Department of and Gynecology, Evanston Hospital, 2650 Ridge, Illinois 6020 1.
0002-9378/78/190343+02$00.20/O
@ 1978 The C. V. Mosby CO
343
A 17-year-old, single, black girl, O-O-l-0, last menstrual period November 8, 1975, presented for examination on January 15, 1976, with a history of having “run out of birth control pills” approximately two and a half months previously. Physical examination was normal except for the uterine cor-
pus, which was enlarged to the size of eight to 10 weeks gestation. The urine pregnancy test was positive. Outpatient elective pregnancy termination was scheduled for January 20, 1976. Preoperative laboratory work, including complete blood count, urinalysis, chest x-ray film, Papanicolaou smear, Venereal Disease Research Laboratory test, and endocervical culture, was unremarkable. With the use of light general anesthesia the uterus was sounded to 14 cm. and the cervix was appropriately dilated. An infusion of 100 cc. of 5 per cent dextrose in water containing 40 U. of oxytocin was begun. A 7 mm. flexible suction curet was introduced into the uterus, and thorough suction curettage was performed with the return of a copious amount of tissue. The uterus was then gently sharply curetted, and polyp forceps were introduced; scanty material was obtained. A final suction curettage was performed. When the suction curet was removed, the tip of the curet was missing. After thorough search of the instrument table, sponge bucket, and suction apparatus, we concluded that the curet tip must have broken off within the uterus. Numerous attempts with various curets and forceps to locate blindly the broken tip were unsuccessful. A plain x-ray film taken on the operating table did not reveal the curet tip. We then decided to terminate the procedure and to attempt visualization of the curet tip by ultrasound the following morning. The ultrasound examination revealed only the presence of clots within the uterus. Communication with the manufacturer confirmed that no similar experiences had been reported. We thought that further attempts to locate the broken tip should be deferred until involution had occurred. The situation was explained to the patient. She was discharged home on a regimen of prophylactic oral tetracycline and ergotrate with careful instructions to search the perineal pads for possible spontaneous expulsion of the curet tip. The patient was seen in the Outpatient Department on February 2, 12, and 26. At each visit she reported no fever or abnormal bleeding. On the first two visits, attempts to remove the curet tip blindly with stone forceps were unsuccessful. Spontaneous normal menses occurred on February 10 and March 9. Because the suction curet tip is nonradiopaque, we were still not certain whether it was present in the uterus. We thought that hysteroscopy might confirm the presence or absence of the broken tip and afford the possibility of removal with the use of direct visualization.’ On March 16, 1976, the patient underwent outpatient hysteroscopy with the use of paracervical block and then light general anesthesia. A hysteroscope* with flexible biopsy forceps was used; 5 per cent dextrose in water was utilized as the irrigating solution. The broken curet tip was found superficially imbedded in the myometrium of the fundus (Fig. 1). Minor dissection dislodged the curet tip, and it was grasped with the forceps and removed (Fig. 2). No intrauterine adhesions were noted, despite the somewhat prolonged original procedure. The patient was observed through one more normal cycle, and then oral contraceptives were restarted.
The flexible Reprint Obstetrics Evanston,
in brief
*Karl California.
Storz
suction curet used in this case has only a Endoscopy-America,
Inc.,
Los
Angeles,
Communications
October
in brief
provement in ventilation is achieved with a 5 mg. oral dose of terbutaline or 0.25 mg. subcutaneously. With 10 mg. orally, there is little further improvement in ventilation, as measured by forced expiratory volume, and significant cardiovascular effects are seen. Moreover, at the 10 mg. dose level, the effect lasts six to seven hours. A single, massive overdose of terbutaline has been inadvertently administered in at least one patient, an elderly woman with asthma who was given 2.5 mg. subcutaneously instead of 0.25 mg. She experienced extreme tachycardia and myocardial &hernia but did not develop pulmonary edema.2 Our patient differed in that she received dexamethasone as well, she was pregnant, and she received more prolonged treatment. Glucocorticoids have been used clinically in massive doses in sepsis and shock and are thought to stabilize lysosome membranes and decrease capillary permeability. Thus, it is unlikely that dexamethasone contributed to the pulmonary edema seen in our patient. Terbutaline and related beta-2-adrenergic drugs are frequently used in combination with glucocorticoids in the management of asthma and do not appear to have caused pulmonary edema. In normal pregnancy, cardiac output increases 30 to 40 per cent. Red cell mass and plasma volume increase 20 to 40 per cent (more in twin pregnancies). Cardiac output increases further with each contraction during labor
and
following
fetal
expulsion,
though
these
changes are less marked if the supine position is avoided. The most likely explanation for the pulmonary edema of our patient is prolonged exposure to a moderately high dose of the adrenergic drug superimposed on the hypervolemic and hyperdynamic cardiovascular status of the laboring pregnant woman. REFERENCES
1. Ersoz, N., and Finestone, S. C.: Adrenaline induced pulmonary edema and its treatment: a report of two cases, Br. J. Anaesth. 43: 709, 1971. 2. Lawyer, C., and Pond, A.: Problems with terbutaiine, N. Engl. J. Med. 296: 821, 1977.
Fetal skull fracture from an apparently trivial motor vehicle accident DAVID C. CUMMING, FRANCES D. WREN, Department and Foothills
FETAL nificant
of Obstetrics Hosp&xl,
M.B., M.B.
and Gynecobgy, Calgary, Alberta,
M.R.C.O.G.
University Canada
of Calgary
LOSS DUE TO TRAUMA usually follows sigmaternal trauma. This case report describes
Reprint requests: Dr. D. C. Gumming, Foothills Hospital, 1403 29th St. N.W., Calgary, Alberta, Canada T2N 2T8. OOOZ-9378/78/190342+02$00.20/O
1, 1978
Am. J. Ohstet. Gynecol.
0 1978 The C. V. Mosby Co
fetal skull fractures and intrauterine apparently trivial maternal injuries motor vehicle accident.
following sustained in a
death
A 22-year-old native Indian woman in the thirty-seventh week of her first pregnancy came to the Emergency Department following a motor vehicle accident on May 5, 1977. She had been the driver of a vehicle that she said “slid into a ditch.” She was not wearing a seat belt. Four passengers in the car suffered only minor bruising. The patient appeared to be intoxicated, with slurred speech, incoordination, and an odor of alcohol. The patient complained of a painful ankle and pain and minor bruising of the left side of the face and forehead. There was no loss of consciousness and no complaint of injury to the abdomen. A roentgenogram demonstrated a crack fracture of the lateral malleolus and a chip fracture of the medial talus with no fracture of the face or skull. Examination of the abdomen revealed IX) external bruising or tenderness. The uterine size was compatible with calculated dates of gestation. The lie was longitudinal with a cephalic presentation. Fetal movement was palpable and the fetal heart tones were normal. Following treatment for the ankle the patient was discharged. On the following day the patient went into labor and was admitted to the delivery unit. Abdominal palpation confirmed the findings of the previous day, again with no abdominal bruising or tenderness. However, no fetal heartbeat was heard. Low-forceps delivery of a stillborn male infant weighing 3,650 grams terminated a brief labor. The maternal surface of tbe placenta demonstrated multiple, small, well-defined areas of hemorrhage. Postmortem examination of the fetus revealed parietal bone fractures, tentorial tears, and subdural hemorrhages bilaterally. The placenta weighed 510 grams with multiple, small, recent placental infarcts. Microscopic examination confirmed the infarcts and showed the presence of a large chorioangioma clearly demarcated from the surrounding normal tissue.
It is unlikely during travel in a modern North American vehicle that major trauma will occur to an occupant in the absence of considerable structural damage to that vehicle.’ The vehicle involved in our case suffered minimal damage while its occupants other than the driver merely had some bruising. Fetal loss in a motor vehicle accident is most likely to be caused first by death of the mother and second by placental separation. The latter may be due to direct trauma or the shearing stresses engendered in the deceleration process. Here shearing forces were probably the cause of the placental changes described although their extent was not sufficient to cause fetal death, The finding of a chorioangioma is incidental, occurring in about 1 per cent of pregnancies. There is no evidence linking it with the changes found. Direct trauma to the fetus as a cause of death is much less common. Fractured skull as a result of a motor vehicle accident is usually associated with a fracture of the maternal pelvis.’ Crosby2 described a fracture due to crushing of the fetal skull between the seat belt buckle and the maternal pelvic. The mechanism of skull fracture in our case is not clearly established as
Communications
Volume 132 Number3
there was no evidence of local trauma to the abdomen of the mother. The most likely explanation is that the fetal head was crushed between the steering wheel rim and the maternal pelvis. This could occur without leaving maternal bruising if the factor involved was a gradually increasing pressure rather than a sudden striking of the fixed object. Hence it would be compatible with the patient’s description of the accident, where the vehicle was described as “sliding into the ditch.” The possibility that apparently minor trauma such as this coexists with major fetal injury raises questions in the management of these cases. In most cases in our hospital patients are admitted for observation but this is frequently because of the accompanying injury rather than the prospect of fetal problems. It is difficult to see a happier outcome for this patient’s pregnancy regardless of management although in retrospect if the diagnosis had been made prior to death urgent abdominal delivery might have been suitable. However, emergency room physicians must be aware of the potential for fetal loss by direct trauma and by separation from shearing stresses and be prepared to admit patients to the hospital. REFERENCES 1. Crosby, W. M.: Trauma during pregnancy: fetal injury, Obstet. Gynecol. Surv. 29: 683, 2. Crosby, W. M.: Pathology of obstetric injuries automobile accident victims, in Brinkhous, Accident Pathology, Washington, D. C., States Government Printing Office, p. 204.
maternal and 1974. in pregnant K. M., editor: 1970, United
Complication of abortion performed with a plastic suction curet: Intrauterine loss of the curet tip THOMAS
W.
THEODORE
McELIN, M.
GIESE,
M.D.,
M.S.
M.D.
Department of Obstetrics and Gynecology, McGaw Medical Cater, Northwestern Univenity, Chicago, Illinois, and Evanston Hospital, Evanston, Illinois THE LEGALIZATION OF ABORTION in the United States has resulted in many reports about equipment, techniques, and complications of first-trimester pregnancy termination. This paper presents an unusual complication of suction curettage-the breakage of the tip of the suction curet-and, to the best of our knowledge, a previously unrecorded complication. Guidelines for expediting diagnosis and management are suggested. requests: Dr. Thomas W. McElin, Department of and Gynecology, Evanston Hospital, 2650 Ridge, Illinois 6020 1.
0002-9378/78/190343+02$00.20/O
@ 1978 The C. V. Mosby CO
343
A 17-year-old, single, black girl, O-O-l-0, last menstrual period November 8, 1975, presented for examination on January 15, 1976, with a history of having “run out of birth control pills” approximately two and a half months previously. Physical examination was normal except for the uterine cor-
pus, which was enlarged to the size of eight to 10 weeks gestation. The urine pregnancy test was positive. Outpatient elective pregnancy termination was scheduled for January 20, 1976. Preoperative laboratory work, including complete blood count, urinalysis, chest x-ray film, Papanicolaou smear, Venereal Disease Research Laboratory test, and endocervical culture, was unremarkable. With the use of light general anesthesia the uterus was sounded to 14 cm. and the cervix was appropriately dilated. An infusion of 100 cc. of 5 per cent dextrose in water containing 40 U. of oxytocin was begun. A 7 mm. flexible suction curet was introduced into the uterus, and thorough suction curettage was performed with the return of a copious amount of tissue. The uterus was then gently sharply curetted, and polyp forceps were introduced; scanty material was obtained. A final suction curettage was performed. When the suction curet was removed, the tip of the curet was missing. After thorough search of the instrument table, sponge bucket, and suction apparatus, we concluded that the curet tip must have broken off within the uterus. Numerous attempts with various curets and forceps to locate blindly the broken tip were unsuccessful. A plain x-ray film taken on the operating table did not reveal the curet tip. We then decided to terminate the procedure and to attempt visualization of the curet tip by ultrasound the following morning. The ultrasound examination revealed only the presence of clots within the uterus. Communication with the manufacturer confirmed that no similar experiences had been reported. We thought that further attempts to locate the broken tip should be deferred until involution had occurred. The situation was explained to the patient. She was discharged home on a regimen of prophylactic oral tetracycline and ergotrate with careful instructions to search the perineal pads for possible spontaneous expulsion of the curet tip. The patient was seen in the Outpatient Department on February 2, 12, and 26. At each visit she reported no fever or abnormal bleeding. On the first two visits, attempts to remove the curet tip blindly with stone forceps were unsuccessful. Spontaneous normal menses occurred on February 10 and March 9. Because the suction curet tip is nonradiopaque, we were still not certain whether it was present in the uterus. We thought that hysteroscopy might confirm the presence or absence of the broken tip and afford the possibility of removal with the use of direct visualization.’ On March 16, 1976, the patient underwent outpatient hysteroscopy with the use of paracervical block and then light general anesthesia. A hysteroscope* with flexible biopsy forceps was used; 5 per cent dextrose in water was utilized as the irrigating solution. The broken curet tip was found superficially imbedded in the myometrium of the fundus (Fig. 1). Minor dissection dislodged the curet tip, and it was grasped with the forceps and removed (Fig. 2). No intrauterine adhesions were noted, despite the somewhat prolonged original procedure. The patient was observed through one more normal cycle, and then oral contraceptives were restarted.
The flexible Reprint Obstetrics Evanston,
in brief
*Karl California.
Storz
suction curet used in this case has only a Endoscopy-America,
Inc.,
Los
Angeles,
