Communications in brief
markedly decreased and fever
subsided over a period of 24 hours. An intravenous pyelogram was essentially within normal limits while cystoscopy revealed erythema of the bladder wall, hut no fistula tract could be identified. Purulent urine drainage subsided in 5 days, but antibiotics were continued for a total of 10 days. At discharge, a 3 by 4 cm mass was still noted on the left side. The patient was readmitted approximately 2 months later and underwent uneventful abdominal hysterectomy and hilateral salpingo-oophorectomy with removal of a lef’t tuboovarian abscess 8 cm in diameter. In addition, a small tuboovarian abscess was identified on the right side. Examination of the bladder revealed only scarring near the left super-ior aspect.
Although rupture of tuboovarian abscesses into the lower colon and rectum is a well-known phenomenon, a review of the literature did not reveal any descriptions of similar rupture or fistula f-ormation &to the bladder. Factors which contribute to fistula formation include surgical trauma, radiation, systemic disease (in particular, malignancy), and aging. The second patient did have a history of previous cesarean section which perhaps played a role in the development of the complication. However, both patients were essentialI) young and none of the other factors were present. It is noteworthy that both patients had intrauterine contraceptive devices and had abscess formation predominantly on one side. Although others have noted unilateral abscess formation in association with an intrauterine contraceptive device,’ it is unclear how such circumstances could contribute to the complications described in this report. However, gynecologists should be alert to this potential, though rare, complication when managing patients with tuboovarian abscess. particularly if in association with intrauterine contraceptive devices. REFERENCES
1. Altman, L.: Ovarian abscess and vaginal fistula. Obstet. Gynecol. 40~321, 1972. 2. Dawood, M. Y., and Birnbaum, ian abscess and intrauterine
S. J.: Unilateral
contraceptive device, Obstet.
Gynecol. 46:429, 1975.
Herpes simplex encephalitis in pregnancy ROBERT
Department Passavant HERPES
01 Obstetrics and Gynecology, North Hospital, Pittsburgh, Pennsylvania
seen in pregnancy, Reprint Obstetrics Pittsburgh,
ENCEPHALITIS isanilness rarely but in those cases which have been
requests: Dr. Robert and Gynceology, North Pennsylvania 15237.
L. King, Department of Hills Passavant Hospital,
1979 The C. V. Mosbv
reported, the results hale been uniformly fatal.” “A definitive diagnosis can br made only if the virus can be isolated from the brain tissue either by brain biopsy 01 at autopsy. Attempts to isolate virus from the cerebrospinal fluid have usually been unrewarding. 1 he diagnosis of herpes encephalitis I-ests upon cliliical srlspicion confirmed by laborator) data. When encephalitis occurs earl! in pregnant), questions arise concerning the management and treatment of the patient and the ultimate well-being of the fetus. We have had such a case with a good outcome for both mother and infant. A 23-year-old woman, para I-O-O-I, was seen for the fix-st prenatal visit on August 24, 1973, with a last menstrual period of June 30, 3973. Physical examination and all laboratory data were normal. On September 20, 1973, the patient called with romplaints of back pain and a temperature of 101” to 103” F. All studies were normal at that time. Since her symptoms continued, she was placed on a regimen of ampicillin. She was examined on September 25 and found to have a normal temperature. complete blood count, and urinalysis. She was seen again on September 26 with a temperature of 103” F and appeared lethargic. She was admitted with a presumptive diagnosis of encephalitis and consultation with a neurotogist and internist was obtained. On admission she also complained of a throbbing headache that was aggravated by movement or bright light. She denied any other visual disturbances or stiff neck. Physical examination on admission revealed her to be lethargic with a temper-ature of 103” F. Pulse was 100 bpm and regular. Blood pressure was 110180 mm Hg. Pupils were equal and active and reacted to light and accommodation. Extraocubr movements were intact. Fundi were normal. There was no nuchal rigidity. The rest of the physical and neurological examination was normal. On admission, a spinal tap was performed with an opening pressure of 120 mm Hg. Total white blood cell count was 203/cu mm, with 43 polymorphonuclear leukocytes, 161 lymphocytes, and 2 red blood cells. Glucose was 67 mgil00 ml; total protein, 87 mg/lOO ml: chloride, 112 mEq/liter. Bacterial cultures were all negative. Viral cultures were obtained and reported on October 18, 1973. as “no viral agent recovered after thirteen days in tissue culture.” The patient’s blood and urine cultures were all negative. White blood cell count on admission was 8. IOOicu mm, with 83 polymorphonuclear leukocytes. 14 lymphocytes, and 3 monocytes. Reticulocyte count was 1.8%. Initial hemoglobin was 12.3 gmi 100 ml, and hematocrit was 35%; these subsequently fell to 11.5 gmilO0 ml and 33%;. respectively. Fasting and 2 hour postprandial blood glucose levels were normal. Heterophile Monospot test was negative. The patient was treated initially with large doses of penicillin. However, when the spinal fluid cultures were reported as negative, all antibiotics were stopped and the patient was treated conservatively with antiemetic drugs and intravenous fluids. The patient’s course, at this point, was one of temperature fluctuating between 101” and 104” F. severe headache. hallucinations, fine tremors, and jerking movements which required restraints. The patient appeared to be unresponsive at times. Many local professors and neurologists were consulted b)
phone. They stated they had not seen any patients with this type of illness but agreed with the presumptive diagnosis of herpes encephalitis and also agreed with the conservative treatment. The possibilities of a brain biopsy were discussed with the staff neurosurgeon, but he did not feel the patient’s condition warranted this procedure. After 10 days, the patient began to improve and the headache disappeared. The patient had an unsteady gait when ambulated but was finally able to be discharged on October 11, 1973. During the patient’s hospital course, the effect of the herpes encephalitis on the developing fetus was discussed with numerous obstetricians and neonatologists. Amniocentesis with viral cultures was ruled out. A search of the literature was carried out but there were no clear cut cases similar to ours. It was the consensus of opinion that the possibility of an affected fetus existed, and if the patient desired an abortion, it should be carried out. The pabent was informed of the possibility prior to discharge, when she was finally rational, and solved our dilemma for us. She stated she could not consider an abortion under any circumstances. The rest of the patient’s pregnancy was uneventful and the patient was admitted on April 19, 1974, in active labor. After a 7 hour labor, the patient was delivered, with low forceps, of a 7 pound, 6 ounce male infant, Apgar score 9. The infant appeared perfectly normal on examination. However, no meconium was passed for over 24 hours, and a barium enema was done to rule out megacolon, which it did. Gastroesophageal reflux was diagnosed and disappeared after 6 months. It was not felt that this was due to the mother’s illness. The infant has been followed up for 4 years and his pediatrician states that he has developed normally, both physically and mentally. The patient has likewise been followed up and has no demonstrable neurological sequelae.
There have been isolated reports of herpes encephalitis in pregnancy but most of the cases resulted in the deaths of both mother and fetus. The mortality rate in the general populations has been recorded by different authors as from 30% to 70%. Cases of herpes encephalitis treated with idoxuridine have been reported2 and the authors felt that certain of their patients did benefit. The side effects of stomatitis, leukopenia, thrombocytopenia, and loss of hair and nails with idoxuride treatment require careful treatment of these patients. Many cases of herpes encephalitis with favorable results for both mother and fetus have no doubt occurred but have never been reported. We have reported here a case in which both survived with no apparent sequelae. It is hoped that this will stimulate the large institutions to evaluate any and all cases of encephalitis in pregnancy in order to have a better idea of the eventual outcome for both mother and fetus. REFERENCES
1. Rawls, W. E., Dyck, P. J., Klass, D. W., Greer, H. D. III, and Herrmann, E. C., Jr.: Encephalitis associated with herpes simplex virus, Ann. Intern. Med. 64:104, 1966. 2. Nolan, D. C., Carruthers, M. M., and Lerner, A. M.: N. Engl. J. Med. 282:10, 1970.
Intrauterine transfusion utilizing linear-array, real-time B scan: A preliminary report LAWRENCE KIRK
M.D. M.D. M.D.
Department Obstetrics and Gynecology, University oj Southern California School of Medicine and Women’s Hospital, Los Angeles CountyllJniversitv of Southern California Medical Center, Los Angeles, California RH IMMUNE GLOBULIN prophylaxis has minimized the number of Rh-sensitized fetuses needing intrauterine transfusion (IUT). When an IUT is needed, patients are referred to a major center for management. Such centers seek new techniques to minimize risks and to improve both short- and long-term outcome. Risks associated with IUT are multiple with a 6.4% fetal death rate. Ultrasound offers an alternative means of localizing the fetal puncture site and minimizing the hazards of ionizing radiation. This is a report of our preliminary experience using linear-array, realtime B scan* for performing IUTs in the Rh-sensitized fetus. The patient is hospitalized when it is decided that an IUT is required. Appropriate laboratory studies and packed red blood cells are obtained. The patient is premeditated and transferred to a special procedures room. The abdomen is prepped and drapped. A realtime scan using a sterile technique (gas sterilization of the transducers) is performed. Fetal spine, bladder, liver, and anterior abdominal wall are localized. A fetal abdominal wall puncture site between the bladder and umbilicus is chosen. Using the real-time scanner, the depth, and angle of insertion of the needle are determined. The maternal puncture site is anesthetized with 1% lidocaine; a No. 16 or 17 Touhy needle is inserted into the amniotic cavity and the needle location is noted. The needle is advanced toward the fetal abdomen until resistance is felt. The needle can be clearly seen on the oscilloscope as it indents the fetal abdomen, which confirms the puncture site. The needle is then quickly advanced into the fetal abdomen. A single Supported in part by National Institutes of Health Grant HD-07086 and by The National Foundation/March of Dimes Grant No. 6-135. Reprint requests: Dr. Lawrence D. Platt, Department of Obstetrics and Gynecology, 1240 N. Mission Road, 58-22, Los Angeles, California 90033. *ADR Model 2130, Advanced Diagostic Research, Tempe, Arizona. Ekolife, Smith Kline Instruments, Sunnyvale, California. OOOZ-9378179/241115+02$00.20/0
1979 The C. V. Mosbv Co.