A case of marked hydramnios in the fifth month of pregnancy

BIJNZEL

:

755

MARKED HYDRAMNIOS

offers a technic for intelligent listening in the eliciting of an adequate history. (3) In very carefully selected cases, it offers a radical therapy which attempt to combine the removal of symptoms with an adjustment or readjustment of an unhappy individual. 1150 FIFTH

AVENUE.

A CASE OF MARKED E. EVERETT

HYDRAMNIOS IN THE OF PREGNA.NCY” BUNZEL,

FIFTH

M.D., NEW YoRK,N.

MONTH

Y.

M

RS. W. P. B., aged twenty-six, white, was seen by me in her first pregnancy in July, 1926. Her menstrual history had always been normal of the twentyeight day type. Her past history had been insignificant except for measles as a child and an appendectomy in 1918. Her expected date of confinement was estimated to be about February 24, 1927. At seven months, an external cephalic version was done. She was delivered at term by low forceps of a 7 pound 14 ounce baby girl, after a labor of seventeen and one-half hours. She made an uneventful recovery, nursing the baby several months. On November 4, 1931, she came to consult me in her third pregnancy, having had another baby girl in September, 1930. This pregnancy was normal, the labor short and easy, and this baby weighed 7 pounds 14 ounces also. Although she nursed for seven months, up to April, 1931, she menstruated regularly after the first two months. Her last period began on May 25, and lasted the usual five days. Therefore at the time she came to me she had just completed the fifth month of her third pregnancy. In the early months of this pregnancy, as with the other two, she had mild nausea and vomiting and under the care of a local physician out of town, noticed nothing unusual until the middle part of her fourth month. At this time both she and the doctor thought her abdomen was larger than it should be for the period of gestation. The uterus from that time on continued to grow rapidly in size and the patient had increasingly severe backache and discomfort, to such a marked degree that she was unable to sleep well even propped up in bed and with three allonal tablets at bedtime. She had felt life on October 16 (at four and one-third months). On physical examination on November 4, her face was flushed, her eyes sunken; she looked tired, and her hands were bluish in color. The abdomen ,appeared to be the size of a full term pregnancy or more. The skin of the abdominal wall was suffused, and blanched on touching it. It was impossible definitely to outline the uterus as it was flaccid and occupied the entire abdominal cavity, but there was a distinct fluid wave throughout. The abdomen measured 106 cm. in diameter at the level of the navel. No fetus or fetal parts could be palpated, nor could a fetal heart be heard. However, I could hear fetal movements. The lungs and heart were normal and the blood pressure 108/70. M.outh temperature was 99” and pulse 130. The cervix was soft, 3/a of an inch long and admitted only the tip of a finger. No presenting part could be felt. A diagnosis of acute hydramnios was made. I advised admission to the hospital at once because of the patient’s extreme discomfort. A blood count showed: Red blood cells 3,730,000, hemoglobin 74, white blood cells 10,200, polymorphonuclear leucocytes 83 per cent. Blood was Type 1 (Jansky). X-ray of the abdomen done the afternoon of admission, November 4, 1931, was somewhat indistinct because of the hydramnios, but a good film was obtained the next morning with the following report: “Films of the abdomen demonstrate an *R&ad

at a meeting

of the New

York

Obstetrical

Society,

January

12, 1932.

756

AMERICAN

JOURNAL

OF

OBSTETRICS

AND

GYNECOLOGY

Within the shadow of the enlarged uterine shadow suggesting polyhpdramnios. uterus we see a single fetal skeleton. The size is greatly out, of proportion to that of the uterus. We see no evidence of fetal anomaly. The size of the fetal shadow suggests a four to five months’ pregnancy.” The problem at this time therefore, was t,o determine if it would be possible to comfort the patitnt sufficiently to permit continuation of the pregnancy. But repeated doses of morphia and lumirtal, given hypodrrmicall~, were without sufficient effect to justify this procedure. The abdominal discomfort, backache and dyspnea were so marked that the patient had to be propped up in bed almost into an erect position. And in addition she could not sleep. Therefore after forty-eight hours ’ trial it was decided to iuterrupt the pregnancy. On November 6, 1931, under nitrous osidc because of the patient’s nervousness and apprehension, and after preparation of the vulva and vagina with iodine and catheterization of the bladder, pelvic examination showed the cervix to he soft, about */l inch in length and readily ndmitt,ing a finger through the internal OS. The cervix was gradually dilated until two fingers could be introduced. h stilettr was then passed through the cervix and the membranes were ruptured high up at 9:40 A.M. Eeeping two fingers in the cervix, the amniotic fluid was allowed to drain off very slowly over a period of fifty minutes. During this time, the uterus began to eontract irregularly, and the patient’s pulse dropped from 108 to 100 at which level it remained throughout the labor. The mcnsuretl amount. of amniotic fluid was 11 quarts. After complete drainage the abdomen was tightly bound. The contractions continued irregularly, and at 11:30 AX., one hour later, there was a sudden gush of blood per vaginam completely saturating the vulva1 towel. From this time on, there was a small amount of oozing of blood from the vagina. Three dosrs of pituitrin were given of minims three, four, and five at 13:30, l:OO, and 2 :13 P.X. respectively until the uterine contractions were definitely regularly established. Eventually, a vertex presented completely covered with membranes. These were ruptured and a very small amount of amniotic fluid escaped. The fetus was delivered at 6 :I1 P.X. and two minutes later came another fetus by the brrech, considerably smallrr than the first. The second fetus was markedly discolored and the cord of the second fetus was very much smallrr than that of the first. There was very littlc bleeding after the birth of the fetuses, but the uterus had little tom, to it and did not contract well. At the end of half an hour, the operator’s hand was introduced into the uterine cavity and 1 placenta with 2 sacs was removed, and although there was no marked bleeding at this time, but, because of continued relaxation of thr uterus, iodoform packing was introduced into the uterine cavity and vagina. While under the anesthetic at the time of rupturing the membranes, a specimen of venous blood was taken: The blood Wassermann was lntcr reported negative and the blood sugar 83 mg. Examination of the amniotic fluid showed a specific gravity of 1.002, no sugar, and the cell count was 1.35 leucoeytes per cubic mm. Fetus A, female, was 28 cm. in length ant1 weighed 17 ounces; fetus B, also female, was 16 cm. long and weighed 8 ounces; neither fetus was macerated though both were stillborn. The smaller fetus was within the amniotic sac containing the excessive liquor amnii. The single placenta with two sacs appeared normal grossly but unfortunately, microscopic study of the placenta and autopsies of the babies were not done. The patient’s convalescence was uneventful and afebrile, the vaginal and uterine packing being removed twenty-two hours after delivery. She was discharged from the hospital on the 1.4th day in excellent condition and feeling well. Prior to discharge a chest x-ray was done which reported nothing to suggest tubereulous inflltration and the heart shadow appeared normal. The follow-up examination made on January 5, 1932 (two months after delivery) found the patient in splendid general condition. The abdominal wall was lax and

HEINZ

: ISTH MIAL

showed marked striations. The pelvic normal anterior position; the adnexa lacerations without erosion. 215 EAST

SEVENTY-SECOND

REPORT

(From

A

757

PRECrNANCY

floor was slightly were normal, and

STREET.

OF A CASE ISTHMIAL HERSCHEL

TUBAL

(For

relaxed; the uterus was in the cervix showed bilateral

discussion,

see page

784.)

OF SIX MONTHS’ UNRUPTURED TUBAL PREG-NANCY

HEINZ, MlD., the Obstetrical

Service,

NEW

BEDFORD,

St. Lube’s

Mass. Hospital)

PREGNANCY actively developing for about six months, without bleeding or rupture, in an ovisac consisting solely of a markedly hypertrophied fallopian tube is an unusual occurrence. Cases partly analogous in one respect or another are to be found in the literature but none exactly comparable to this one, for which reason I report it in some detail. The patient, a French woman of twenty-seven, was admitted to the obstetric service of St. Luke’s Hospital on the fifth of September, 1931. Her chief complaint was of intermittent pain of one month’s duration, the pain being referable to the lower abdomen. The present illness began with the cessation of menses on March 11, 1931. Believing herself to be pregnant, the patient consulted her family physician for prenatal care. For four months nothing unusual was noted by either the patient or her physician. After this period the patient remarked upon the absence of any signs of fetal life. Continued observation at no time revealed fet,al movements or fetal heart sounds. The growth, however, of what was supposed to be the pregnant uterus was perfectly normal and consistent with a normally progressing pregnancy. For a month before hospital entry the patient complained of intermittent lower abdominal pain at times accompanied by nausea and vomiting and occasionally of sufficient severity as to require the administration of morphia. The examination of the abdomen by the family physician at the time of these attacks disclosed no apparent intra-abdominal pathology. Two weeks before entry the blood pressure began to rise. During the forty-eight hours previous to admission the systolic pressure rose from 160 to 208. The blood pressure in two previous pregnancies had never been The present illness was unaccompanied by fever, bowel or urinary disover 120. turbance, or any evidence of bleeding, either external or internal. The past history was essentially negative. The patient had had two normal pregnancies terminating by low forceps. The menses previous to the present illness had been regular, of the twenty-eight day type. The flow was moderate in amount, of normal character, and of four to five days’ duration. The patient’s last period was There was no history of dysmenorrhea, intermenstrual normal in every respect. bleeding or vaginal discharge. No history of venereal disease could be obtained from either the patient or her husband. The patient was a fairly well developed and nourished woman apparently in moderate pain. The color was good. Temperature 99.4” F., pulse 88, and respirations 20. The blood pressure was 208 over 134. The general physical examination was negative except for the presence of marked The breasts were full and somewhat sensitive, consistent with the dental caries. mammary enlargement of pregnancy. Abdominal examination revealed the presence of a smoothly globular, freely movable maas, reaching to, or a little above the umbilicus with the patient in a reclining position. This mass was firm and tense, resembling in feel the uteru! in a case of ablatio placentae. It was somewhat tender to pressure. During the examination the