Necrosis of myometrial choriocarcinoma with fulminating sepsis complicating chemotherapy for trophoblastic tumor.

We report a patient who developed metastatic gestational choriocarcinoma following delivery of a normal, healthy child that, however, was anemic and required blood transfusion. The patient developed secondary postpartum hemorrhage over a period of several weeks and required curettage and myometrial contractants to control the bleeding. At the time of diagnosis the patient had extensive pulmonary metastases and ultrasound showed full penetration of the myometrium by tumor. Immediately following the second course of chemotherapy with etoposide, methotrexate, and actinomycin D, alternating with cyclophosphamide and vincristine, the patient developed sepsis associated with a uteroperitoneal fistula and required hysterectomy. The sepsis was associated with disseminated intravascular coagulopathy and adult respiratory distress syndrome. However, the patient's tumor was exquisitely sensitive to chemotherapy and with good intensive care unit support and chemotherapy the survived without residual scar except for the loss of reproductive function. There are two lessons to be learned from these events: (1) The syndrome of secondary postpartum hemorrhage with a fetus that is anemic spells a diagnosis of choriocarcinoma; and (2) color Doppler flow vaginal ultrasound performed at the time of presentation of trophoblastic tumors may be useful to show full penetration of the myometrium by tumor which may be a warning of possible scar rupture in a subsequent pregnancy.

Current trends in HIV-related hospital admissions and their impact on hospital resource utilization in Ontario.

OBJECTIVE: To assess changes in patterns of hospital admissions, in frequency of admissions and in average length of stay (ALOS) at a tertiary HIV referral centre, and to investigate the overall impact of care for patients with HIV infection of AIDS on peer hospitals in Ontario. DESIGN: Descriptive study. PARTICIPANTS: Data were obtained on patients with HIV infection or AIDS treated at the Wellesley Hospital in Toronto for the fiscal years (May 1 to Apr. 31) 1990-91, 1991-92 and 1992-93, and on admissions for HIV or AIDS in 9 peer hospitals in Ontario during the same period. INTERVENTIONS: For the Wellesley Hospital, review of medical records of HIV-related admissions to determine the reasons for admission and to examine concurrent illnesses. For the Wellesley Hospital Hospital and peer hospitals, analysis of changes in ALOS and Resource Intensity Weights (RIWs). RESULTS: Between May 1, 1990, and Apr. 31, 1993, the number of admissions for treatment of Pneumocystis carinii pneumonia (PCP) fell, but admissions for respiratory infections other than PCP remained very common, although they decreased slightly. Overall, infection remained the main reason for admission. The frequency of gastrointestinal complications necessitating admission increased. The frequency of admissions remained high, although the ALOS decreased significantly. In the period between Apr. 1, 1991, and Mar. 31, 1994, the proportion of HIV-related discharges and total hospital discharges among the 9 peer hospitals remained stable. The HIV-related ALOS decreased substantially. Although the HIV-related average RIW decreased slightly, this measure and the mortality rate are still much higher for HIV-related admissions than for overall admissions. CONCLUSIONS: This contemporary survey suggests that nonrespiratory infection complications have become the main reason for admission of patients with HIV infection or AIDS, but that the HIV tertiary hospitals are coping with the load of HIV-related admissions and the high average RIW associated with these patients by reducing the ALOS.