COMMUNICATIONS IN BRIEF
This section is suitable for reporting cases, results of therapeutic trials, and descriptions of new procedures or instruments. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Peritoneal-cutaneous fistula secondary to a perforated Dalkon shield LAURA SLAUGHTER , M.D. DAVID J . MORRIS, M.D. Women's Hospital, Los Angeles, California
THE F OLLOWI N G case report is presented as an unuusual manifestation of a perforated Dalkon shield . M. B., A 25-year-old black woman, gravida 5, para 4, therapeutic abortion I, had a Dalkon shield inserted 6 weeks post partum in June, 1972. The insertion was extremely painful and she requested immediate removal but agreed to a 3 week trial period. During this interval she experienced spotting and cramping which subsided completely by her next appointment. At that time, she was informed after routine pelvic examination that the device was no longer present and she was given oral contraceptives. In the interim prior to admission she had an abortion in January, 1973, was treated for ·gonococcalsalpingitis:on August 14, 1973, and had at least four documented visits to a family-planning clinic for birth control pills. On September 21 , 1974, she was seen in the emergency room because a 3 by 3 em. infraumbilical mass which had been present for over a year had suddenly become painful and drained purulent material. A l em. abscess was incised and drained; bacteroides was cultured from the abscess site. Despite these measures, the abscess continued to drain and she was seen on three subsequent occasions. Finally, on December 2, 1974, the abscess cavity, which was now 2 by 2 em., yielded a black, single-knotted string. A Hat plate and lateral x-ray disclosed a Dalkon shield just beneath the abdominal wall. At surgery, the Dalkon shield was found encircled by omentum and fibrous tissue in a 4 x 3 em. mass. The string led from the peritoneal cavity through the abdominal wall to just beneath the skin and is represented as a
Fig. 1. Lateral x-ray. radiolucent tract on lateral x-ray (see Fig. 1). The abscess was confined to the abdominal wall.
Whitson, Israel, and Bernstein, 1 in a recent report on intrauterine Dalkon shields, noted that the majority of cases occurred in multiparas with a standard size device in the puerperium and were associated with a significant chronic adhesive reaction necessitating removal. They carefully outlined a workup for the localization of IUD's suspected to have perforated. This case and others reporting multiple IUD insertions 2 emphasize to the clinician that the absence of IUD strings must not be assumed to represent expulsion per vagina and demands further investigation to rule out perforation. REFERENCES
Reprint requests: Laura Slaughter, M.D., Room L-946 , Women's Hospital, 1240 Mission Rd. , Los Angeles, California 90033.
I. Whitson, L. G., Israel, R. , and Bernstein, G . S. : T he
extrauterine Dalkon shield, Obstet. Gynecol. 44: 418, 1974.
206
Volume 124 Number 2
Communications in brief 207
2. Porges, R. F.: Complications associated with the unsuspected presence of intrauterine contraceptive devices, AM. j. 0BSTET. GYNECOL. 116: 579, 1973.
Maternal midtrimester sepsis in association with the intrauterine contraceptive device: Early histopathologic findings E. D. BIGGERSTAFF, M.D. M. T. MENUTTI, M.D.
J. F. YETTER, M.D. R. E. ROGERS, M.D., F.A.C.O.G.* Departments of Obstetrics and Gynecology and Pathology, Madigan Army Medical Center, Tacoma, Washington
midtrimester sepsis in association with the shield-type intrauterine contraceptive device (IUD) has now been reported by several authors. 1- 4 The mechanisms by which this infection occurs and is disseminated are unknown. The clinical presentation is unusual in that there are often symptoms of generalized infection, a "flu-like" syndrome, with
MATERNAL
absent or mild symptoms and signs of localized pelvic infection. The case reported here is similar to those previously described, but is presented because of the somewhat unusual microscopic findings. A 24-year-old white woman, gravida 1, para 0, ABO, presented at 16 weeks' gestation with a shield-type IUD in place and a 12 hour history of chills and fever. She had no other complaints. General physical examination revealed a temperature of 104.6° F. rectally, a blood pressure of 110/60 mm. Hg and a pulse of 120, but was otherwise unremarkable. Pelvic examination confirmed a 14 to 16 week size intrauterine pregnancy. The uterus was mildly tender, and the fetal heart tones were 200 b.p.m. After appropriate laboratory studies and bacterial cultures were obtained, therapy with antibiotics and pitocin was begun. The fetus, placenta, and IUD were passed vaginally and a curettage was performed. Postoperatively, the patient responded rapidly to continued antibiotic therapy and there were no complications. Maternal blood and placental cultures grew E. coli. Histopathologic examination of the specimen revealed extensive bacterial colonization on the maternal side of the membranes (Fig. 1). Microscopic sections of the placenta and fetal organs were unremarkable. The mechanism by which severe maternal sepsis occurs in association with an intrauterine pregnancy and a shield-type IUD has been speculated on by the authors reporting previous cases. Because of the rapid Reprint requests: Edward D. Biggerstaff, M.D., Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington 98431.
Fig. I. Amnion, demonstrating epithelial surface (above) and numerous gram-negative bacilli (below). A single polymorphonuclear leukocyte is present. (Hematoxylin and Eosin; x416).
dinicai deterioration due to septicemia when signs of severe localized pelvic infection were often absent, Christian 1 felt that there might be a mechanical factor which allowed vascular dissemination of bacteria at a time when the infection might be otherwise locally contained. In those cases in which the microscopic examination of the pregnancy has been described,
well-established chorioamnionitis and placentitis were most often noted. We believe that the case reported here represents an earlier example of this clinical problem than those generally reported. The finding of large numbers of bacteria on the maternal side of the membranes, without amnionitis or placentitis, is unusual. One might speculate that this could explain the dissemination of bacteria into the maternal vascular system, resulting in severe maternal septicemia prior to the development of the classical signs and symptoms of septic abortion. This is only speculation and in no way attempts to expiain how this phenomenon occurs with the IUD. We feel, however, that the histologic findings in this case are consistent with the clinical course seen in this patient and perhaps of other similar reported cases.
REFERENCES 1. Christian, 0. D.: Maternal deaths associated 'vith an
intrauterine device, AM. J. 0BSTET. GYNECOL. 119: 441, 1974. 2. Zuckerman,]. E., and Stubblefield, P. G.: E. coli septicemia in pregnancy associated with the shield intrauterine contraceptive device., Am. ]. Obstet. Gynecol. 120: 951, 1974.
3. Wiles, P. ]., and Zeiderman, A.M.: Pregnancy complicated by intrauterine contraceptive devices, Obstet. Gynecol. 44: 484, 1974. 4. Hurt, W. G.: Septic pregnancy associated with Dalkon shield intrauterine device, Obstet. Gynecol. 44: 491, 1974.
This section is suitable for reporting cases, results of therapeutic trials, and descriptions of new procedures or instruments. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Peritoneal-cutaneous fistula secondary to a perforated Dalkon shield LAURA SLAUGHTER , M.D. DAVID J . MORRIS, M.D. Women's Hospital, Los Angeles, California
THE F OLLOWI N G case report is presented as an unuusual manifestation of a perforated Dalkon shield . M. B., A 25-year-old black woman, gravida 5, para 4, therapeutic abortion I, had a Dalkon shield inserted 6 weeks post partum in June, 1972. The insertion was extremely painful and she requested immediate removal but agreed to a 3 week trial period. During this interval she experienced spotting and cramping which subsided completely by her next appointment. At that time, she was informed after routine pelvic examination that the device was no longer present and she was given oral contraceptives. In the interim prior to admission she had an abortion in January, 1973, was treated for ·gonococcalsalpingitis:on August 14, 1973, and had at least four documented visits to a family-planning clinic for birth control pills. On September 21 , 1974, she was seen in the emergency room because a 3 by 3 em. infraumbilical mass which had been present for over a year had suddenly become painful and drained purulent material. A l em. abscess was incised and drained; bacteroides was cultured from the abscess site. Despite these measures, the abscess continued to drain and she was seen on three subsequent occasions. Finally, on December 2, 1974, the abscess cavity, which was now 2 by 2 em., yielded a black, single-knotted string. A Hat plate and lateral x-ray disclosed a Dalkon shield just beneath the abdominal wall. At surgery, the Dalkon shield was found encircled by omentum and fibrous tissue in a 4 x 3 em. mass. The string led from the peritoneal cavity through the abdominal wall to just beneath the skin and is represented as a
Fig. 1. Lateral x-ray. radiolucent tract on lateral x-ray (see Fig. 1). The abscess was confined to the abdominal wall.
Whitson, Israel, and Bernstein, 1 in a recent report on intrauterine Dalkon shields, noted that the majority of cases occurred in multiparas with a standard size device in the puerperium and were associated with a significant chronic adhesive reaction necessitating removal. They carefully outlined a workup for the localization of IUD's suspected to have perforated. This case and others reporting multiple IUD insertions 2 emphasize to the clinician that the absence of IUD strings must not be assumed to represent expulsion per vagina and demands further investigation to rule out perforation. REFERENCES
Reprint requests: Laura Slaughter, M.D., Room L-946 , Women's Hospital, 1240 Mission Rd. , Los Angeles, California 90033.
I. Whitson, L. G., Israel, R. , and Bernstein, G . S. : T he
extrauterine Dalkon shield, Obstet. Gynecol. 44: 418, 1974.
206
Volume 124 Number 2
Communications in brief 207
2. Porges, R. F.: Complications associated with the unsuspected presence of intrauterine contraceptive devices, AM. j. 0BSTET. GYNECOL. 116: 579, 1973.
Maternal midtrimester sepsis in association with the intrauterine contraceptive device: Early histopathologic findings E. D. BIGGERSTAFF, M.D. M. T. MENUTTI, M.D.
J. F. YETTER, M.D. R. E. ROGERS, M.D., F.A.C.O.G.* Departments of Obstetrics and Gynecology and Pathology, Madigan Army Medical Center, Tacoma, Washington
midtrimester sepsis in association with the shield-type intrauterine contraceptive device (IUD) has now been reported by several authors. 1- 4 The mechanisms by which this infection occurs and is disseminated are unknown. The clinical presentation is unusual in that there are often symptoms of generalized infection, a "flu-like" syndrome, with
MATERNAL
absent or mild symptoms and signs of localized pelvic infection. The case reported here is similar to those previously described, but is presented because of the somewhat unusual microscopic findings. A 24-year-old white woman, gravida 1, para 0, ABO, presented at 16 weeks' gestation with a shield-type IUD in place and a 12 hour history of chills and fever. She had no other complaints. General physical examination revealed a temperature of 104.6° F. rectally, a blood pressure of 110/60 mm. Hg and a pulse of 120, but was otherwise unremarkable. Pelvic examination confirmed a 14 to 16 week size intrauterine pregnancy. The uterus was mildly tender, and the fetal heart tones were 200 b.p.m. After appropriate laboratory studies and bacterial cultures were obtained, therapy with antibiotics and pitocin was begun. The fetus, placenta, and IUD were passed vaginally and a curettage was performed. Postoperatively, the patient responded rapidly to continued antibiotic therapy and there were no complications. Maternal blood and placental cultures grew E. coli. Histopathologic examination of the specimen revealed extensive bacterial colonization on the maternal side of the membranes (Fig. 1). Microscopic sections of the placenta and fetal organs were unremarkable. The mechanism by which severe maternal sepsis occurs in association with an intrauterine pregnancy and a shield-type IUD has been speculated on by the authors reporting previous cases. Because of the rapid Reprint requests: Edward D. Biggerstaff, M.D., Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington 98431.
Fig. I. Amnion, demonstrating epithelial surface (above) and numerous gram-negative bacilli (below). A single polymorphonuclear leukocyte is present. (Hematoxylin and Eosin; x416).
dinicai deterioration due to septicemia when signs of severe localized pelvic infection were often absent, Christian 1 felt that there might be a mechanical factor which allowed vascular dissemination of bacteria at a time when the infection might be otherwise locally contained. In those cases in which the microscopic examination of the pregnancy has been described,
well-established chorioamnionitis and placentitis were most often noted. We believe that the case reported here represents an earlier example of this clinical problem than those generally reported. The finding of large numbers of bacteria on the maternal side of the membranes, without amnionitis or placentitis, is unusual. One might speculate that this could explain the dissemination of bacteria into the maternal vascular system, resulting in severe maternal septicemia prior to the development of the classical signs and symptoms of septic abortion. This is only speculation and in no way attempts to expiain how this phenomenon occurs with the IUD. We feel, however, that the histologic findings in this case are consistent with the clinical course seen in this patient and perhaps of other similar reported cases.
REFERENCES 1. Christian, 0. D.: Maternal deaths associated 'vith an
intrauterine device, AM. J. 0BSTET. GYNECOL. 119: 441, 1974. 2. Zuckerman,]. E., and Stubblefield, P. G.: E. coli septicemia in pregnancy associated with the shield intrauterine contraceptive device., Am. ]. Obstet. Gynecol. 120: 951, 1974.
3. Wiles, P. ]., and Zeiderman, A.M.: Pregnancy complicated by intrauterine contraceptive devices, Obstet. Gynecol. 44: 484, 1974. 4. Hurt, W. G.: Septic pregnancy associated with Dalkon shield intrauterine device, Obstet. Gynecol. 44: 491, 1974.
