Volume Number
122 6
Communications
in brief
791
sure 16 per cent of the proteins found in amniotic fluid, and this percentage appeared to be composed of alpha globulin. As T-H glycoprotein migrates during immunoelectrophoresis like an alpha seric protein, the above-mentioned results may be related to our findings. The presence of a glycoprotein of fetal renal origin in amniotic fluid may be a new parameter enabling the study of fetal kidney development. Furthermore, our results seem to give new evidence on the contribution of fetal urine to-the formation of amniotic fluid. REFERENCES
Fig. 1. Double immunodiffusion in agar. A, Pooled amniotic fluid concentrated 20 times; B, pooled normal urine concentrated 10 times; C, standard of T-H glycoprotein, 10 mg. per 100 ml.; D, pooled maternal serum; E, pooled umbilical cord serum. human urine. This is of renal origin and produced in the ascending limb of Henle and the distal convoluted tubules.2, s Lewis and associates,” studying the ontogenic development of Tamm and Horsfall (T-H) glycoprotein in the rat kidney with an immunofluorescent method, reported that it appears only after birth and that an adult-type pattern develops rapidly in the neonate during the first 3 days. No similar studies have been made in the human fetal kidney. Although amniotic fluid proteins have been extensively investigated by all possible methods, the existence of a protein of fetal renal origin in this compartment has not yet been established. The aim of this paper is to report the presence of T-H glycoprotein in amniotic fluid. Samples of amniotic fluid obtained by transabdominal amniocentesis from 10 normal pregnant women, whose gestational ages ranged between 32 and 40 weeks, were dialyzed during 24 hours at 4O C. against distilled water, pooled, and concentrated 20 times. This concentrate was tested with the technique of double immunodiffusion in agar against rabbit serum anti-human T-H, which was obtained as previously described.5 A reaction of total identity was observed among pure glycoprotein, adult normal urine, and amniotic fluid (Fig. 1, rl, B, and C). The same precipitation pattern was observed with serum anti-human T-H previously absorbed with a placental homogenized pool. Precipitation lines with umbilical cord and maternal sera were absent (Fig. 1, D and E) According to our findings, neither placental nor maternal origin of the glycoprotein present in amniotic fluid may be assumed. Fischbacher and Quinlivan,c using disc electrophoresis, have reported the presence of more bands in alpha-l globulin areas in amniotic fluid than in serum. The same authors, using radial immunodiffusion, could not mea-
1. Tamm, I., and Horsfall, F. L.: Proc. Sot. Exp. Biol. Med. 74: 108, 1950. 2. Friedmann, T.: Experientia 22: 624, 1966. 3. Schenk, E. A., Schwartz, R. H., and Lewis, R. A.: Lab. Invest. 25: 92, 1971. 4. Lewis, R. A., Schwartz, R. H., and Schenk, E. A.: Lab. Invest. 26: 728, 1972. 5. Mazzuchi, N., Pecarovich, R., Ross, N., Rodriguez, I., and Sanguinetti, C. M.: .I. Lab. Clin. Med. 84: 771, 1974. 6. Fischbacher, P. H., and Quinlivan, W. L. G.: AM. J. OBSTET. GYNECOL. 108: 1051, 1970.
Abdominal induced EUGENE SALLY
fetus
following
abortion M. E.
SILVERMAN, RYDEN, M.D.
M.D.
Wayne County General Hospital, Eloise, Michigan, and the Department of Pathology, The University of Michigan Medical Center, Ann Arbor, Michigan UT E RI N E P E R F 0 RAT IO N complicates up to 0.7 per cent of cases of suction abortion1 and is relatively more common and more serious in patients aborted after 12 weeks’ gestation.* Even though perforation does not always require laparotomy, this complication must be recognized when it occurs so that the patient may be followed carefully. Occult perforations may lead to hemorrhage, bowel obstruction, infection, and death. This communication reports an unusual complication of an unrecognized uterine perforation following therapeutic abortion by suction curettage, namely, an extruded fetus within a pelvic abscess which caused bowel obstruction. A 25-year-old woman, gravida six, para five, abortus one, was admitted to Wayne County General Hospital because of abdominal pain, fever, nausea, and vomiting. One month earlier, suction curettage had been performed elsewhere to terminate a 12 week pregnancy, as estimated by uterine size. Date of last menstrual period Reprint requests: of Pathology, 1335 48104.
Dr. Eugene E. Catherine
M. Silverman, Department St., Ann Arbor, Michigan
792
Communications
in brief
Fig.
1. X-ray
showing
fetal
skeleton
was unclear because of intermittent use of birth control pills. On the following day, she developed crampy lower abdominal pain, nausea, and fever. She was admitted to another hospital for 2 weeks, during which time she was treated with intravenous penicillin for presumed endometritis. she was given oral tetracycline. Following discharge, Nausea and vomiting worsened in the 2 days before admission, and the vomitus developed a feculent odor. On admission to Wayne County General Hospital, she was thin and dehydrated. The abdomen was tender and distended, and bowel sounds were hyperactive. A tender mass was palpated to the right of the uterus. Radiographs of the abdomen showed multiple air-filled, dilated loops of small bowel consistent with intestinal obstruction and calcific densities resembling a fetal skeleton in the region of the pelvic mass (Fig. 1) At laparotomy there was a perforation of the uterine fundus with an adjacent abscess involving several loops of small bowel. The proximal small bowel was markedly distended; the distal bowel was shrunken. The small bowel was dissected free of the abscess which was removed along with the uterus and right Fallopian tube. A dilated loop of small bowel was perforated, with peritoneal soilage. This loop of bowel was resected. Two units of whole blood were transfused during the operation. A postoperative fever was present for 2 days but responded to antibiotics, and she was discharged 14 days after operation.
(arrow)
on right
side of pelvis.
Fifty-seven days postoperatively, she was readmitted with acute icteric hepatitis, from which she recovered uneventfully. The abscess contained a fragmented, necrotic fetus adjacent to a perforation in the right uterine corn”. The Fallopian tube was intact and did not appear to be the site of implantation. We postulate that the fetus was forced uterine perforation into the pelvis at the tage, by either the instruments or forceful tractions following the uterine perforation. fetus acted as a foreign body, enhancing tion. This case is reported to emphasize the recognizing uterine perforation after suction to alert others to an unusual complication namely, expulsion of fetal parts into the
through the time of curetuterine conThe necrotic abscess formaimportance of abortion and of perforation. abdomen.
REFERENCES
1. Stewart, G. K., and Goldstein, P.: Medical and surgical complications of therapeutic abortions, Obstet. Gynecol. 49: 539, 1972. 2. Berger, G. S., et al.: Maternal mortality associated with legal abortions in New York State; July 1, 1970June 30, 1972, Obstet. Gynecol. 43: 31.5, 1974.
122 6
Communications
in brief
791
sure 16 per cent of the proteins found in amniotic fluid, and this percentage appeared to be composed of alpha globulin. As T-H glycoprotein migrates during immunoelectrophoresis like an alpha seric protein, the above-mentioned results may be related to our findings. The presence of a glycoprotein of fetal renal origin in amniotic fluid may be a new parameter enabling the study of fetal kidney development. Furthermore, our results seem to give new evidence on the contribution of fetal urine to-the formation of amniotic fluid. REFERENCES
Fig. 1. Double immunodiffusion in agar. A, Pooled amniotic fluid concentrated 20 times; B, pooled normal urine concentrated 10 times; C, standard of T-H glycoprotein, 10 mg. per 100 ml.; D, pooled maternal serum; E, pooled umbilical cord serum. human urine. This is of renal origin and produced in the ascending limb of Henle and the distal convoluted tubules.2, s Lewis and associates,” studying the ontogenic development of Tamm and Horsfall (T-H) glycoprotein in the rat kidney with an immunofluorescent method, reported that it appears only after birth and that an adult-type pattern develops rapidly in the neonate during the first 3 days. No similar studies have been made in the human fetal kidney. Although amniotic fluid proteins have been extensively investigated by all possible methods, the existence of a protein of fetal renal origin in this compartment has not yet been established. The aim of this paper is to report the presence of T-H glycoprotein in amniotic fluid. Samples of amniotic fluid obtained by transabdominal amniocentesis from 10 normal pregnant women, whose gestational ages ranged between 32 and 40 weeks, were dialyzed during 24 hours at 4O C. against distilled water, pooled, and concentrated 20 times. This concentrate was tested with the technique of double immunodiffusion in agar against rabbit serum anti-human T-H, which was obtained as previously described.5 A reaction of total identity was observed among pure glycoprotein, adult normal urine, and amniotic fluid (Fig. 1, rl, B, and C). The same precipitation pattern was observed with serum anti-human T-H previously absorbed with a placental homogenized pool. Precipitation lines with umbilical cord and maternal sera were absent (Fig. 1, D and E) According to our findings, neither placental nor maternal origin of the glycoprotein present in amniotic fluid may be assumed. Fischbacher and Quinlivan,c using disc electrophoresis, have reported the presence of more bands in alpha-l globulin areas in amniotic fluid than in serum. The same authors, using radial immunodiffusion, could not mea-
1. Tamm, I., and Horsfall, F. L.: Proc. Sot. Exp. Biol. Med. 74: 108, 1950. 2. Friedmann, T.: Experientia 22: 624, 1966. 3. Schenk, E. A., Schwartz, R. H., and Lewis, R. A.: Lab. Invest. 25: 92, 1971. 4. Lewis, R. A., Schwartz, R. H., and Schenk, E. A.: Lab. Invest. 26: 728, 1972. 5. Mazzuchi, N., Pecarovich, R., Ross, N., Rodriguez, I., and Sanguinetti, C. M.: .I. Lab. Clin. Med. 84: 771, 1974. 6. Fischbacher, P. H., and Quinlivan, W. L. G.: AM. J. OBSTET. GYNECOL. 108: 1051, 1970.
Abdominal induced EUGENE SALLY
fetus
following
abortion M. E.
SILVERMAN, RYDEN, M.D.
M.D.
Wayne County General Hospital, Eloise, Michigan, and the Department of Pathology, The University of Michigan Medical Center, Ann Arbor, Michigan UT E RI N E P E R F 0 RAT IO N complicates up to 0.7 per cent of cases of suction abortion1 and is relatively more common and more serious in patients aborted after 12 weeks’ gestation.* Even though perforation does not always require laparotomy, this complication must be recognized when it occurs so that the patient may be followed carefully. Occult perforations may lead to hemorrhage, bowel obstruction, infection, and death. This communication reports an unusual complication of an unrecognized uterine perforation following therapeutic abortion by suction curettage, namely, an extruded fetus within a pelvic abscess which caused bowel obstruction. A 25-year-old woman, gravida six, para five, abortus one, was admitted to Wayne County General Hospital because of abdominal pain, fever, nausea, and vomiting. One month earlier, suction curettage had been performed elsewhere to terminate a 12 week pregnancy, as estimated by uterine size. Date of last menstrual period Reprint requests: of Pathology, 1335 48104.
Dr. Eugene E. Catherine
M. Silverman, Department St., Ann Arbor, Michigan
792
Communications
in brief
Fig.
1. X-ray
showing
fetal
skeleton
was unclear because of intermittent use of birth control pills. On the following day, she developed crampy lower abdominal pain, nausea, and fever. She was admitted to another hospital for 2 weeks, during which time she was treated with intravenous penicillin for presumed endometritis. she was given oral tetracycline. Following discharge, Nausea and vomiting worsened in the 2 days before admission, and the vomitus developed a feculent odor. On admission to Wayne County General Hospital, she was thin and dehydrated. The abdomen was tender and distended, and bowel sounds were hyperactive. A tender mass was palpated to the right of the uterus. Radiographs of the abdomen showed multiple air-filled, dilated loops of small bowel consistent with intestinal obstruction and calcific densities resembling a fetal skeleton in the region of the pelvic mass (Fig. 1) At laparotomy there was a perforation of the uterine fundus with an adjacent abscess involving several loops of small bowel. The proximal small bowel was markedly distended; the distal bowel was shrunken. The small bowel was dissected free of the abscess which was removed along with the uterus and right Fallopian tube. A dilated loop of small bowel was perforated, with peritoneal soilage. This loop of bowel was resected. Two units of whole blood were transfused during the operation. A postoperative fever was present for 2 days but responded to antibiotics, and she was discharged 14 days after operation.
(arrow)
on right
side of pelvis.
Fifty-seven days postoperatively, she was readmitted with acute icteric hepatitis, from which she recovered uneventfully. The abscess contained a fragmented, necrotic fetus adjacent to a perforation in the right uterine corn”. The Fallopian tube was intact and did not appear to be the site of implantation. We postulate that the fetus was forced uterine perforation into the pelvis at the tage, by either the instruments or forceful tractions following the uterine perforation. fetus acted as a foreign body, enhancing tion. This case is reported to emphasize the recognizing uterine perforation after suction to alert others to an unusual complication namely, expulsion of fetal parts into the
through the time of curetuterine conThe necrotic abscess formaimportance of abortion and of perforation. abdomen.
REFERENCES
1. Stewart, G. K., and Goldstein, P.: Medical and surgical complications of therapeutic abortions, Obstet. Gynecol. 49: 539, 1972. 2. Berger, G. S., et al.: Maternal mortality associated with legal abortions in New York State; July 1, 1970June 30, 1972, Obstet. Gynecol. 43: 31.5, 1974.
