Cronje, Hendrik S

Urbani, Gian

South African Medical Journal (SAMJ)

October 2003, Vol. 93, No. 10  SAMJSCIENTIFIC LETTERSconcluded that: (i) FA was under no obligation to disclose thefact that he had been treated for a sexually transmitted diseasemore than 12 months before applying for membership; (ii)information relating to the treatment of ‘acute conditionstreatable immediately’ and not related to a chronic condition, isnot material and need not be disclosed; and (iii) chronicconditions may be regarded as material for purposes ofdisclosure.The scheme was therefore ordered to reinstate FA'smembership retrospectively.Although it is still not clear from this case what exactly doesconstitute material information for purposes of the Act, thisdecision makes clear what does not. Members cannot bepenalised for not disclosing information about a condition thatwas diagnosed or treated 12 months before applying formembership and that is not present at the time of application.In effect, this ruling means that medical schemes can no longerrequire applicants to disclose full details of all medicalconditions suffered by them at any period before joining thescheme. The Council does not appear to regard failure todisclose a medical condition present more than 12 monthsbefore joining the scheme, as material. Furthermore, acuteconditions present at the time of application need not bedisclosed if they are treatable immediately and do not relate toa chronic condition.In terms of Section 29A(2) (a) of the Act, a scheme may onlyimpose a 12-month condition-specific waiting period on newmembers in respect of a condition for which medical advice,diagnosis, care or treatment was recommended or receivedwithin the 12-month period ending on the date on which anapplication for membership was made. It will not assist ascheme to argue, as Compcare did in the present case,  that it isentitled to impose a condition-specific waiting period inrespect of a particular condition unless there is clear evidencethat the member received medical advice, diagnosis, care ortreatment for that condition within the 12-month period endingon the date on which an application for membership wasmade.Teboho MotebeleMarlise RichterAIDS Law ProjectCentre for Applied Legal StudiesUniversity of the WitwatersrandJohannesburgEndnotes1. See for example the case of Mutual & Federal Insurance Co Ltd v Oudtshoorn Municipality 1985(1) SA 419 (A).2. The South African Medical Association's Human Rights and Ethical Guidelines on HIV: AManual for Medical Practitioners clearly states that: ‘A patient’s HIV status may only bedisclosed to a person or group if that patient consents to it being made known to that personor group of persons....’.3. In the case Jansen van Vuuren and Another NNO v Kruger, case no. 1993 (4) SA 733, theAppellate Division ruled that it is vital to keep a patient's HIV status confidential.4. The judgement is available on the AIDS Law Project website: http://www.alp.org.za.776To the Editor: Cervical pregnancy, first described by Rubin in1911,1 is a rare but dangerous type of ectopic pregnancy withan incidence ranging from 1:1 000 to 1:18 000 pregnancies.2Initially, cervical pregnancy was usually diagnosed at the timeof evacuation in the operating room with severe tohaemorrhage. Early diagnosis by ultrasound3 led to animprovement in morbidity, but the next breakthrough was inthe early 1980s when methotrexate was introduced as a methodof treatment.3 Although internal iliac artery ligation has beenused in some cases, uterine artery embolisation came into useduring the 1990s and proved to be very effective in controllingacute bleeding.4 In this report we describe the first case ofcervical pregnancy in an HIV-infected patient, treated byuterine artery embolisation and methotrexate.Case reportA 24-year-old woman, gravida 2, para 1, presented with 16weeks’ amenorrhoea followed by lower abdominal pain and amild, dark vaginal bleeding of 2 days’ duration. The historydid not reveal any information of importance.Her temperature was 36.7°C, pulse rate 54 beats/minute,blood pressure 127/78 mmHg and respiratory rate 20/minute.There was no detectable lymphadenopathy. The abdomen wassoft with normal bowel sounds and the uterus was notpalpable. Vaginal examination revealed a barrel-shaped cervixwith membranes visible within the external cervical os, whichwas 1 cm dilated.An ultrasound examination revealed an hourglass-shapeduterus with the gestational sac within the cervix. A fetal polewas visible without a heartbeat and the size of the gestationalsac was compatible with a pregnancy of 8 weeks’ duration. Thepatient tested positive for HIV infection with a CD4 count of530 x 109/l.Primary treatment consisted of uterine embolisation viacatheterisation of the femoral arteries, with the aid ofCervical pregnancy in an HIV-infected patient treated byuterine artery embolisation and methotrexateLetters Oct  11/5/03  8:23 AM  Page 776SCIENTIFIC LETTERScontinuous X-ray imaging. Spongostan standard gelatin sponge(Johnson and Johnson Medical, Skipton, UK) was cut into smallblocks (< 1 cm diameter), suspended in a saline solution withheparin and injected into the uterine arteries with animmediate and marked reduction in uterine blood flow.Following the procedure, a single dose of 50 mg methotrexatewas given intramuscularly.Three days after embolisation the patient experienced mildsuprapubic pain with a haemorrhagic vaginal discharge. Anultrasound examination performed on the fourth day showedan absent gestational sac with only a thickened endocervicalepithelium. On discharge from hospital the patient receivedcontraception in the form of depo-medroxyprogesteroneacetate 150 mg intramuscularly.Two weeks later she presented again with acute pain justbelow the umbilicus. She acknowledged having had coitusduring these 2 weeks. Her temperature was 37.5°C, pulse rate100/minute, blood pressure 119/63 mmHg and respiratory rate28/minute. The lower abdomen was tender on palpationwithout guarding. Excitation tenderness of the cervix waspresent on vaginal examination, but the cervix itself was closedand of normal size. The adnexae were moderately tender onboth sides.An ultrasound examination revealed a normal cervixwithout other pathology in the pelvis. Analysis of her bloodgases revealed a mild respiratory alkalosis with the carbondioxide pressure (pCO2) 26 mmHg, oxygen pressure (pO2) 95mmHg and pH 7.5. Her haemoglobin value was 10.6 g/dl witha leucocytosis of 14.9 x 109/l. The human chorionicgonadotropin (HCG) level had decreased from 39 to less than10 mIU/l.The patient was admitted with the clinical diagnosis ofpelvic inflammatory disease (PID) and treated withclindamycin intravenously. The next day she improvedsignificantly and on the second day she was discharged fromhospital on oral clindamycin.DiscussionThere are different treatment options when a cervicalpregnancy is diagnosed. Surgical evacuation is no longer thefirst line of treatment since it is impossible to remove thetrophoblast completely. Medical treatment with methotrexate isthe current first option in the management of a cervicalpregnancy, with a 94% success rate.5 An importantcontraindication is acute haemorrhage which is present inabout 30% of cases.6 The remaining treatment options includeabdominal hysterectomy, endocervical tamponade and uterineartery embolisation. Although embolisation results in acutehypoxia of the uterus, collateral blood supplies will restorenormal blood flow within 5 - 6 weeks. Due to the hypoxia,methotrexate should be given before embolisation if the twomethods are applied together.Methotrexate is not the ideal first line treatment in HIV-positive patients as it suppresses immunity in patients who arealready immune compromised. Our patient, with a normalCD4 count of 530 x 109/l, received methotrexate before her HIVstatus was known and she developed pelvic inflammatorydisease afterwards. Owing to the risk of infection,immunosuppressants should be limited in patients with a CD4count of more than 200 x 109/l.Gian UrbaniHendrik S CronjéDepartment of Obstetrics and GynaecologyUniversity of the Free StateBloemfontein1. Rubin IC. Cervical pregnancy. Surg Gynecol Obstet 1911; 13: 625-633.2. Yankowitz J, Leake J, Hugguns, G, et al. Cervical ectopic pregnancy: review of the literatureand report of a case treated by single-dose methotrexate therapy. Obstet Gynecol Surv 1990;45: 405-414.3. Raskin MM. Diagnosis of cervical pregnancy by ultrasound: a case report. Am J ObstetGynecol 1978; 130: 234-235.4. Cosin JA, Bean M, Grow D, et al. The use of methotrexate and arterial embolization to avoidsurgery in a case of cervical pregnancy. Fertil Steril 1997; 67: 1169-1171.5. Carson SA, Buster JE. Ectopic pregnancy. N Engl J Med 1993; 329: 1174-1181.6. Ushakov FB, Elchalal U, Aceman PJ, Schenker G. Cervical pregnancy: Past and future. ObstetGynecol Surv 1996; 52: 45-58.777October 2003, Vol. 93, No. 10  SAMJChanges in the patient population attending a primary healthcare clinic in rural South Africa between 1991 and 2001To the Editor: Serosurveys in the last decade indicate that theprevalence of HIV infection has risen in Hlabisa district,KwaZulu-Natal, from 4% in 1992, to 14% in 1995 and 35% in2002.1,2 The impact of the HIV epidemic on the patientpopulation attending local hospitals has been reportedpreviously.3 In particular, there has been a marked increase inadmissions for tuberculosis and other HIV-associatedconditions. However, there are few data on the impact of theepidemic on the burden of illness seen at primary health cliniclevel. Furthermore, in 1996, primary health care became free forall in South Africa, whereas previously patients paid a nominalfee to see clinic staff. The impact of this change on theattendance at primary care clinics is unknown. Suchinformation is needed for planning effective responses aimedat reducing unnecessary referrals and admissions to hospitaland to enable more effective deployment of health careworkers.To investigate possible changes in the patient populationLetters Oct  11/5/03  8:23 AM  Page 777

Cervical pregnancy in an HIV-infected patient treated by uterine artery embolisation and methotrexate

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Cervical pregnancy in an HIV-infected patient treated by uterine artery embolisation and methotrexate

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