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Asymptomatic axial rotation of a full-term uterus through 180 degrees
164
AMERICAN
JOl:RNAI,
OF OBSTETRICS AND GYNECOIOGT
Occasionally in patients with amenorrhea or prolonged bleeding it is difficult to obtain tissue with the sharp rurette. It is then necessary to use the Bureh punch to really “bite” out a piece of uterine wall with its very thin layer of endometrium. The methods described above for obtaining au endometrial biopsy and the uterine index have been in use in our c:linic for tivr years, and after removing more than 1,500 specimens from the uterus without, any disasters, we feel that it has proved Although :I few specimens have to be satisfactory, simple, inexpensive, and safe. only one patient has miscarried, shown unmistakable evidence of early pregnancy, and this was a sterility patient who had l\a(l two weeks of dribbling and probably was about to miscarry spontaneously. In studying patients with endocrine disorders and sterility, endometrial biopsy must be done and the uterine index found, hut it is very important. to emphasize that ihis method of biopsy cannot be used to exclude ranter of the body and endocervix. In a suspertecl (xase it real curettage of the whole uterine cavity should be carried out.
I. A method is described for obtaining endometrial biopsies and for measuring 111~ proportions of the uterine cervix and body. 2. The method has been in use in the Ovarian Dysfunction Clinic of the Massachusetts General Hospital for over five years, ant1 in no patient has any serious dificulty or sequeln occurred. :i. The use of these two methods of investigation are recommended in the study of endocrine and sterility problems, but, the method will not replace careful curettage: in patients with suspected tumors of the inside of the uterus.
REFERENCES Xealcer, 8. R. : Human Sterility, Bturgis, 9., and Meigs, .J. V.: Am.
ASYMPTOMATIC
Baltimore, 1934, Williams and Wilkins J. Surg. 33: 369 and 391, 1936.
AXIAL ROTATION OF A FULL-TERM THROUGH 180 DEGREES
BERNARD J. HANLEY, (Prom
T HE
KD.,
the St. Vincents
Los
ANGET,ES,
Company.
TJTERIJH
CALIF.
Hospital)
full-term uterus is quite frequently dext,rorotated; however, axial rotation through 180 degrees is exceedingly rare. The literature has recently been reviewed by Robinson and Du Vall,l Feinor and Kaldor,z and H. F. Day.3 Adding my case to the list makes a total of 36 such cases reported. Of these, 29 cases had associated pathology or uterine anomalies that may account for their rotation, and in 7 cases, including mine, no apparent reason for the rotation could be noted. The case 1 am reporting is the only one, so far as I have been able to determine, which was entirely asymptomatic. Mrs. W., aged 31, gravida i, para 0, was first seen on Dec. 21, 1937, stating that her last menstrual period began October 29, 1937. Her past history revealed that she had had an appendectomy and removal of the gall bladder in 1924, a suspension of the right kidney in 1925, and a dilatation and curettage with radium implantation for menorrhagia in 1926. Her menstrual periods began at 13 years of age, interval twenty-six days, duration four days, with slight dysmenorrhea. Physical examination revealed a young woman, of fair complexion, height 5 feet 2 inches, weight 122. Head and neck negative, heart and lungs clear, high right rectus scar, well healed, with no tenderness, also a scar over the right kidney region. Pelvic examination showed the outlet marital, glands negative, support adequate, cervix posterior, uterus anterior, size of a six weeks’ pregnancy and freely movable, no palpable adnexal masses, the diagonal conjugate was not reached, all bony pelvic
HANLEY
Fig .. I.--A drawing of the uterus
:
ROTATION
OF
FUI,L-TERM
reconstructed from x-ray and 180’ to the right, with the fetus
Fig
2.-Photograph
of x-ray
taken
‘C’TERUS
1
surgery, illustrating a rotai :ion in transverse presentation.
July
26, 1938.
166
AMERICAN
JOCRNAI,
OF
OBSTETRICS
AND
GTNECOI,OGY
findings
were well within the range of normal. Joints and ext,remities normal, all active. Laboratory findings : Wassermann negative, hemoglobin ‘i3 per cent, R..B.C. 4,910,000, urine negative for albumin and sugar. Patient was seen at two-week intervals during the remainder of her pregnancy, during which time all findings were well within the range of normal. On July 5, 1938, a diagnosis of a transverse presentation was made. This was subsequently confirmed by an x-ray on July 26, 1938. Patient was subsequently seen at weekly intervals, and an elective cesarean section was decided upon for Aug. 7, 1938, which was approximately full term. Patient went into labor spontaneously on Aug. 5, 193% at 1O:OO A.~x., was admitted to St. Vincents Hospital immediately. At the time of admission patient was having weak uterine cont,ractions, and two hours later was operated upon under spinal anesthesia. A low midline incision was made in order to enter the lower uterine segment. IJpon opening the peritoneal cavity it was found that the uterus was rotated to the right IS0 degrees, such that its posterior surface was presenting at t,he wound. The left round ligament was stretched diagonally across the ut,erus and measured about :! cm. in diameter. The left broad ligament. with tube and ovary was lying as shown in Fig. 1. Rather than attempt to deliver the fetus through a posterior incision it was decided to explore the upper abdomen, so the abdominal incision was lengthened to slightly above the umbilicus, thus enabling the hand to be introduced well over the funtlus. The abdomen was ‘@rely free of adhesions and the uterus seemed mobile such that with my hand up over the fundus I was able to rotate the uterus back to its normal position. A low classical operation was then done; a five-pound, nimounce fetus lying as a transverse presentation was found. A breech extraction was done on the fetus and the placenta and membranes extracted manually. -4 gauze pack ivas then put in the uterus with a shuttle through the cervix. The uterine wound was then closed in the usual manner. The ut,erus was then drawn up out of the abdomen and a thorough inspection made with no gross pathology or abnormalities noted. Abdomen was closed in the usual manner. ller postoperative convalescence was uneventful. Mother and baby were discharged in good condition on the fourteenth postoperat,ive day. E’ollow-up examination on Sept. 6, 1938, showed the patient in good general condition, the uterus involuted, anterior, and freely movable, no palpable adnexal masses. Her subsequent course to date has been uneventful. reflcsfv
DISCUSSIOS
In deciding upon an elective presentation of the fetus was probably to the use of radium evidence of stenosis could be tion caused a rotation of the this patient did not complain type. A case of this type raises ability of attempting a manual tempted, the procedure should tainly the patient should not
cesarean in this case it was felt that the transverse caused by stenosis of the lower uterine segment, due for menorrhagia ten years previous. However, no found at operation. Whether the transverse presentauterus or vice versa I am unable to state. Certainly of pain such as might accompany a rotation of this one other very pertinent question, that is, the adviscorrection of transverse presentation. If this is atbe cautious and gentle, with no undue force, and cerhave anest,hesia during the attempted conversion. REFERENCES
(I) F&or England
Eobilason and Dzl Vail: J. Obst. & Gynec. Brit. Emp. AM. J. 0s~. & GYSEC. 20: 88, 1930. (3) and Kaldor: J. Med. 213: 605, 1935.
38: Day,
55
19:ll. h.
P. :
(2) New
AMERICAN
JOl:RNAI,
OF OBSTETRICS AND GYNECOIOGT
Occasionally in patients with amenorrhea or prolonged bleeding it is difficult to obtain tissue with the sharp rurette. It is then necessary to use the Bureh punch to really “bite” out a piece of uterine wall with its very thin layer of endometrium. The methods described above for obtaining au endometrial biopsy and the uterine index have been in use in our c:linic for tivr years, and after removing more than 1,500 specimens from the uterus without, any disasters, we feel that it has proved Although :I few specimens have to be satisfactory, simple, inexpensive, and safe. only one patient has miscarried, shown unmistakable evidence of early pregnancy, and this was a sterility patient who had l\a(l two weeks of dribbling and probably was about to miscarry spontaneously. In studying patients with endocrine disorders and sterility, endometrial biopsy must be done and the uterine index found, hut it is very important. to emphasize that ihis method of biopsy cannot be used to exclude ranter of the body and endocervix. In a suspertecl (xase it real curettage of the whole uterine cavity should be carried out.
I. A method is described for obtaining endometrial biopsies and for measuring 111~ proportions of the uterine cervix and body. 2. The method has been in use in the Ovarian Dysfunction Clinic of the Massachusetts General Hospital for over five years, ant1 in no patient has any serious dificulty or sequeln occurred. :i. The use of these two methods of investigation are recommended in the study of endocrine and sterility problems, but, the method will not replace careful curettage: in patients with suspected tumors of the inside of the uterus.
REFERENCES Xealcer, 8. R. : Human Sterility, Bturgis, 9., and Meigs, .J. V.: Am.
ASYMPTOMATIC
Baltimore, 1934, Williams and Wilkins J. Surg. 33: 369 and 391, 1936.
AXIAL ROTATION OF A FULL-TERM THROUGH 180 DEGREES
BERNARD J. HANLEY, (Prom
T HE
KD.,
the St. Vincents
Los
ANGET,ES,
Company.
TJTERIJH
CALIF.
Hospital)
full-term uterus is quite frequently dext,rorotated; however, axial rotation through 180 degrees is exceedingly rare. The literature has recently been reviewed by Robinson and Du Vall,l Feinor and Kaldor,z and H. F. Day.3 Adding my case to the list makes a total of 36 such cases reported. Of these, 29 cases had associated pathology or uterine anomalies that may account for their rotation, and in 7 cases, including mine, no apparent reason for the rotation could be noted. The case 1 am reporting is the only one, so far as I have been able to determine, which was entirely asymptomatic. Mrs. W., aged 31, gravida i, para 0, was first seen on Dec. 21, 1937, stating that her last menstrual period began October 29, 1937. Her past history revealed that she had had an appendectomy and removal of the gall bladder in 1924, a suspension of the right kidney in 1925, and a dilatation and curettage with radium implantation for menorrhagia in 1926. Her menstrual periods began at 13 years of age, interval twenty-six days, duration four days, with slight dysmenorrhea. Physical examination revealed a young woman, of fair complexion, height 5 feet 2 inches, weight 122. Head and neck negative, heart and lungs clear, high right rectus scar, well healed, with no tenderness, also a scar over the right kidney region. Pelvic examination showed the outlet marital, glands negative, support adequate, cervix posterior, uterus anterior, size of a six weeks’ pregnancy and freely movable, no palpable adnexal masses, the diagonal conjugate was not reached, all bony pelvic
HANLEY
Fig .. I.--A drawing of the uterus
:
ROTATION
OF
FUI,L-TERM
reconstructed from x-ray and 180’ to the right, with the fetus
Fig
2.-Photograph
of x-ray
taken
‘C’TERUS
1
surgery, illustrating a rotai :ion in transverse presentation.
July
26, 1938.
166
AMERICAN
JOCRNAI,
OF
OBSTETRICS
AND
GTNECOI,OGY
findings
were well within the range of normal. Joints and ext,remities normal, all active. Laboratory findings : Wassermann negative, hemoglobin ‘i3 per cent, R..B.C. 4,910,000, urine negative for albumin and sugar. Patient was seen at two-week intervals during the remainder of her pregnancy, during which time all findings were well within the range of normal. On July 5, 1938, a diagnosis of a transverse presentation was made. This was subsequently confirmed by an x-ray on July 26, 1938. Patient was subsequently seen at weekly intervals, and an elective cesarean section was decided upon for Aug. 7, 1938, which was approximately full term. Patient went into labor spontaneously on Aug. 5, 193% at 1O:OO A.~x., was admitted to St. Vincents Hospital immediately. At the time of admission patient was having weak uterine cont,ractions, and two hours later was operated upon under spinal anesthesia. A low midline incision was made in order to enter the lower uterine segment. IJpon opening the peritoneal cavity it was found that the uterus was rotated to the right IS0 degrees, such that its posterior surface was presenting at t,he wound. The left round ligament was stretched diagonally across the ut,erus and measured about :! cm. in diameter. The left broad ligament. with tube and ovary was lying as shown in Fig. 1. Rather than attempt to deliver the fetus through a posterior incision it was decided to explore the upper abdomen, so the abdominal incision was lengthened to slightly above the umbilicus, thus enabling the hand to be introduced well over the funtlus. The abdomen was ‘@rely free of adhesions and the uterus seemed mobile such that with my hand up over the fundus I was able to rotate the uterus back to its normal position. A low classical operation was then done; a five-pound, nimounce fetus lying as a transverse presentation was found. A breech extraction was done on the fetus and the placenta and membranes extracted manually. -4 gauze pack ivas then put in the uterus with a shuttle through the cervix. The uterine wound was then closed in the usual manner. The ut,erus was then drawn up out of the abdomen and a thorough inspection made with no gross pathology or abnormalities noted. Abdomen was closed in the usual manner. ller postoperative convalescence was uneventful. Mother and baby were discharged in good condition on the fourteenth postoperat,ive day. E’ollow-up examination on Sept. 6, 1938, showed the patient in good general condition, the uterus involuted, anterior, and freely movable, no palpable adnexal masses. Her subsequent course to date has been uneventful. reflcsfv
DISCUSSIOS
In deciding upon an elective presentation of the fetus was probably to the use of radium evidence of stenosis could be tion caused a rotation of the this patient did not complain type. A case of this type raises ability of attempting a manual tempted, the procedure should tainly the patient should not
cesarean in this case it was felt that the transverse caused by stenosis of the lower uterine segment, due for menorrhagia ten years previous. However, no found at operation. Whether the transverse presentauterus or vice versa I am unable to state. Certainly of pain such as might accompany a rotation of this one other very pertinent question, that is, the adviscorrection of transverse presentation. If this is atbe cautious and gentle, with no undue force, and cerhave anest,hesia during the attempted conversion. REFERENCES
(I) F&or England
Eobilason and Dzl Vail: J. Obst. & Gynec. Brit. Emp. AM. J. 0s~. & GYSEC. 20: 88, 1930. (3) and Kaldor: J. Med. 213: 605, 1935.
38: Day,
55
19:ll. h.
P. :
(2) New