- Email: [email protected]
Acute hydramnios in early pregnancy
Acute hydramnios in early pregnancy Report of a case
JAMES M. MUELLER, M.D. DAVID G. DECKER, M.D. Rochester, Minnesota
T H E presence of an excessive amount of amniotic fluid not infrequently complicates pregnancy. Occasionally, the rapid accumulation of fluid in early pregnancy presents a very real diagnostic and therapeutic problem. It is the purpose of this paper to report a case illustrating this problem.
nor fetal heart tones were detected. Pelvic examination confirmed the presence of a mass originating in the pelvis. The cervix was firm and closed. albumin and Urinalysis showed grade grade 1 pus (on the basis of 1 to 4). The concentration of hemoglobin was 9.8 Gm. per 10'0 ml. of blood, and leukocytes numbered 4,700 per cubic millimeter of blood. Blood urea nitrogen measured 12 mg. per 100 ml. A roentgenogram of the thorax was normal, and the pregnancy test was positive. A roentgenogram of the abdomen showed a large soft-tissue mass. There was some questionable evidence of fetal bony parts, but these were too small to account for the large intra-abdominal mass. Forty-eight hours later the chorionic gonadotropins were reported as measuring 400,155 international rat units per 24 hours of urinary excretion. The level of fasting blood sugar was 66 mg. per 100 mi. Surgical exploration seemed indicated since conservative treatment failed to alleviate the symptoms or control the rapid abdominal enlargement. At 18 weeks of gestation the abdomen was opened, revealing a term-sized uterus. Although there was no uterine manipulation or obvious blood loss, the patient suddenly lapsed into profound shock. A total of 5,000 ml. of bloody fluid was removed through a small anterior uterine incision. The upper two thirds of the placenta separated spontaneously under direct vision, and premature uniovular twins were delivered. The infants, each measuring 15 em. (crown to rump), died shortly thereafter. The uterus contracted well, and furth!'r bleeding was minimal. The patient made an uneventful recovery.
The patient is a 28-year-old white woman who had previously had 5 full-term ·pregnancies without incident. There was no family history of congenital anomalies. She first consulted her local physician 13 weeks after her last menstrual period, considering herself to be again pregnant. She complained of dyspnea, backache, heartburn, and frequency, for which she received symptomatic treatment. Pronounced abdominal enlargement was also present at that time. A pregnancy test was not done. She was kept under observation for 3 weeks, and during this interval her symptoms became rapidly more severe and she gained 21 pounds. Roentgenography of the abdomen was negative; there were no fetal heart tones. Her physician referred the patient to the Mayo Clinic with a diagnosis of hydatidiform mole. \Vhen first examined by us, the patient was obviously in considerable distress. Vital signs, including a blood pressure of 120 mm. Hg systolic and 82 mm. Hg diastolic, were within normal limits. A mild apical systolic murmur was present. The abdominal cavity was filled with a huge cystic mass; neither fetal motion From the Section of Obstetrics and Gynecology, Mayo Clinic and Mayo Foundation. Presented at a meeting of the Minnesota Obstetrical and Gynecological Society, Rochester, Minnesota, April 28, 1962.
493
Februa:y l
494 Mueller and Decker
Comment
Hydramnios remains an enigma. Presently then~ are no data confirming either the overproduction or impaired excretion theories of excessive accumulation of amniotic fluid. Criteria vary, but the incidence of acute hydramnios has been stated to be one in 12,500 live birthsl The association of congenital anomalies has been stressed by many authors. 2 - 4 Chief among the anomalies are abnormalities of the central nervous system and the gastrointestinal and unnary tracts. Placental choriohemangiomas and normal uniovular twin pregnancies have been noted frequently.'· "· 6 Acute hydramnios occurs most often in the twentieth to the twenty-eighth week of pn'gnancy. 1 • c Mueller~ has reported a case in the fourteenth week of pregnancy; this is apparently the earliest recorded case. Symptoms are referable to rapid uterine enlargement and include dyspnea, orthopnea, backache, fatigue, cough, rapid weight gain, abdominal enlargement, urinary urgency and frequency, and constipation. The conditions to be considered in the differential diagnosis include multiple pregnancy, hydatidiform mole, ascites, and ovarian cyst. Numerous complications of acute hydramnios are recorded.H· 7 Premature labor and prolapse of the cord are not uncommon. The incidence of abruptio placentae is increased and, hence, so are maternal morbidity and mortality. Postpartum uterine atony can present a serious problem. Buckingham and associates 8 reported a fetal mortality rate of 81 per cent in 13 cases,
REFERENCES
1. Eastman, N. J., and Hellman, L. M., editors: Williams Obstetrics, New York, 1961, Appleton-Century-Crofts, Inc., pp. 603-608. 2. Mueller, P. F.: AM. J. 0BST. & GYNEC. 56: 1069, 1948. :). Brown, D. B.: Practitioner 178: 723, 1957. +. Moya, Frank, Apgar, Virginia, James, L. S., and Berrien, Cornelia: J. A. M. A. 173: 1552, 1960. 5. MacafeE', C. H. G.: J. Obst. & Gynaec. Brit. Emp. 57: 171, 1950.
Am. J. Obst. & Gynec.
while Mueller~ reported 100 per cent fetal mortalitv in 4 cases. Macafee 5 stated that when roentgenograms of the abdomen are normaL 33 per cent of hydramnios case~ will result in a dead baby; fetal mortality soars to 94.6 per cent with abnormal films. The frequent association of maternal diabetes or toxemia and fetal anomalies or erythroblastosis fetalis undoubtedly makes fetal prognosis poorer. Treatment of acute hydramnios is varied. fled rest, sedation, diuretics, and restricted salt intake all have been tried, with little success. Amniotomy is advocated by some, hut Gough 7 reported considerable risk from hemorrhage. Abdominal paracentesis has been tried but is best reserved for those cases approaching viability; 2 ' 6 Riwtfl reported on 50 cases in which this treatment was used without mishap, but the hazards would seem obvious. Summary
An unusual case of acute hydramnios originating at 13 weeks of gestation is reported. No maternal cause could be found, and the presence of normal uniovular twins was the apparent reason for this hydramniotic state. Histologically, both placental and fetal tissues were normaL Uterine evacuation became necessary when conscn,ative treatment failed to control the accumulation of amniotic fluid. Surgical shock existed but fortunately placental separation occurred under direct vision and could be managed promptly. This condition represents a diagnostic problem early in the second trimester of pregnancy.
6. Erskine, J. P.: J. Obst. & Gynaec. Brit. Emp. 51: 549, 1944. 7. Gough, H. M.: J. Obst. & Gynaec. Brit. Emp. 66: 473, 1959. 8. Buckingham, J. C., McElin, T. W., Bowers, V. M., and McVay. John: Obst. & Gynec. 15: 652, 1960. 9. Rivett, L. C.: A~r. J. 0BST. & GYNEC 52: 890, 1946.
200 First St., S. W. Rochester, Minnesota
JAMES M. MUELLER, M.D. DAVID G. DECKER, M.D. Rochester, Minnesota
T H E presence of an excessive amount of amniotic fluid not infrequently complicates pregnancy. Occasionally, the rapid accumulation of fluid in early pregnancy presents a very real diagnostic and therapeutic problem. It is the purpose of this paper to report a case illustrating this problem.
nor fetal heart tones were detected. Pelvic examination confirmed the presence of a mass originating in the pelvis. The cervix was firm and closed. albumin and Urinalysis showed grade grade 1 pus (on the basis of 1 to 4). The concentration of hemoglobin was 9.8 Gm. per 10'0 ml. of blood, and leukocytes numbered 4,700 per cubic millimeter of blood. Blood urea nitrogen measured 12 mg. per 100 ml. A roentgenogram of the thorax was normal, and the pregnancy test was positive. A roentgenogram of the abdomen showed a large soft-tissue mass. There was some questionable evidence of fetal bony parts, but these were too small to account for the large intra-abdominal mass. Forty-eight hours later the chorionic gonadotropins were reported as measuring 400,155 international rat units per 24 hours of urinary excretion. The level of fasting blood sugar was 66 mg. per 100 mi. Surgical exploration seemed indicated since conservative treatment failed to alleviate the symptoms or control the rapid abdominal enlargement. At 18 weeks of gestation the abdomen was opened, revealing a term-sized uterus. Although there was no uterine manipulation or obvious blood loss, the patient suddenly lapsed into profound shock. A total of 5,000 ml. of bloody fluid was removed through a small anterior uterine incision. The upper two thirds of the placenta separated spontaneously under direct vision, and premature uniovular twins were delivered. The infants, each measuring 15 em. (crown to rump), died shortly thereafter. The uterus contracted well, and furth!'r bleeding was minimal. The patient made an uneventful recovery.
The patient is a 28-year-old white woman who had previously had 5 full-term ·pregnancies without incident. There was no family history of congenital anomalies. She first consulted her local physician 13 weeks after her last menstrual period, considering herself to be again pregnant. She complained of dyspnea, backache, heartburn, and frequency, for which she received symptomatic treatment. Pronounced abdominal enlargement was also present at that time. A pregnancy test was not done. She was kept under observation for 3 weeks, and during this interval her symptoms became rapidly more severe and she gained 21 pounds. Roentgenography of the abdomen was negative; there were no fetal heart tones. Her physician referred the patient to the Mayo Clinic with a diagnosis of hydatidiform mole. \Vhen first examined by us, the patient was obviously in considerable distress. Vital signs, including a blood pressure of 120 mm. Hg systolic and 82 mm. Hg diastolic, were within normal limits. A mild apical systolic murmur was present. The abdominal cavity was filled with a huge cystic mass; neither fetal motion From the Section of Obstetrics and Gynecology, Mayo Clinic and Mayo Foundation. Presented at a meeting of the Minnesota Obstetrical and Gynecological Society, Rochester, Minnesota, April 28, 1962.
493
Februa:y l
494 Mueller and Decker
Comment
Hydramnios remains an enigma. Presently then~ are no data confirming either the overproduction or impaired excretion theories of excessive accumulation of amniotic fluid. Criteria vary, but the incidence of acute hydramnios has been stated to be one in 12,500 live birthsl The association of congenital anomalies has been stressed by many authors. 2 - 4 Chief among the anomalies are abnormalities of the central nervous system and the gastrointestinal and unnary tracts. Placental choriohemangiomas and normal uniovular twin pregnancies have been noted frequently.'· "· 6 Acute hydramnios occurs most often in the twentieth to the twenty-eighth week of pn'gnancy. 1 • c Mueller~ has reported a case in the fourteenth week of pregnancy; this is apparently the earliest recorded case. Symptoms are referable to rapid uterine enlargement and include dyspnea, orthopnea, backache, fatigue, cough, rapid weight gain, abdominal enlargement, urinary urgency and frequency, and constipation. The conditions to be considered in the differential diagnosis include multiple pregnancy, hydatidiform mole, ascites, and ovarian cyst. Numerous complications of acute hydramnios are recorded.H· 7 Premature labor and prolapse of the cord are not uncommon. The incidence of abruptio placentae is increased and, hence, so are maternal morbidity and mortality. Postpartum uterine atony can present a serious problem. Buckingham and associates 8 reported a fetal mortality rate of 81 per cent in 13 cases,
REFERENCES
1. Eastman, N. J., and Hellman, L. M., editors: Williams Obstetrics, New York, 1961, Appleton-Century-Crofts, Inc., pp. 603-608. 2. Mueller, P. F.: AM. J. 0BST. & GYNEC. 56: 1069, 1948. :). Brown, D. B.: Practitioner 178: 723, 1957. +. Moya, Frank, Apgar, Virginia, James, L. S., and Berrien, Cornelia: J. A. M. A. 173: 1552, 1960. 5. MacafeE', C. H. G.: J. Obst. & Gynaec. Brit. Emp. 57: 171, 1950.
Am. J. Obst. & Gynec.
while Mueller~ reported 100 per cent fetal mortalitv in 4 cases. Macafee 5 stated that when roentgenograms of the abdomen are normaL 33 per cent of hydramnios case~ will result in a dead baby; fetal mortality soars to 94.6 per cent with abnormal films. The frequent association of maternal diabetes or toxemia and fetal anomalies or erythroblastosis fetalis undoubtedly makes fetal prognosis poorer. Treatment of acute hydramnios is varied. fled rest, sedation, diuretics, and restricted salt intake all have been tried, with little success. Amniotomy is advocated by some, hut Gough 7 reported considerable risk from hemorrhage. Abdominal paracentesis has been tried but is best reserved for those cases approaching viability; 2 ' 6 Riwtfl reported on 50 cases in which this treatment was used without mishap, but the hazards would seem obvious. Summary
An unusual case of acute hydramnios originating at 13 weeks of gestation is reported. No maternal cause could be found, and the presence of normal uniovular twins was the apparent reason for this hydramniotic state. Histologically, both placental and fetal tissues were normaL Uterine evacuation became necessary when conscn,ative treatment failed to control the accumulation of amniotic fluid. Surgical shock existed but fortunately placental separation occurred under direct vision and could be managed promptly. This condition represents a diagnostic problem early in the second trimester of pregnancy.
6. Erskine, J. P.: J. Obst. & Gynaec. Brit. Emp. 51: 549, 1944. 7. Gough, H. M.: J. Obst. & Gynaec. Brit. Emp. 66: 473, 1959. 8. Buckingham, J. C., McElin, T. W., Bowers, V. M., and McVay. John: Obst. & Gynec. 15: 652, 1960. 9. Rivett, L. C.: A~r. J. 0BST. & GYNEC 52: 890, 1946.
200 First St., S. W. Rochester, Minnesota