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Interstitial pregnancy
INTERSTITIAL FIVE MONTHS'
PREGNANCY”
GESTATION, WITH AN OBRERVATIOK OF THE YHE~NOMENON OF RU~TVKE AT TIN%: TIME 0~ OPERATION
T
HE diagnosis of this type of tubal pregnancy before rupture is most difficult to make. Unless one has this condition in mind together with its criteria, the diagnosis map not he clear even at the tinie of operation, particularly if rupture has not occurred. ‘I’. K., 2i years 0111, caolorerl, married uint~ >-ears, 11:1(1 not Iwcn able to bec*onw pregnant. She last menstruated on Maw11 1, 19%. There were no unusual symptoms aside from right lower quadrant ashes which were worse at the time of her menstrual molimina. She was first seen in the prenatal czlinic of the Cook County Hospital on June 27, 19.38 and no abnormal findings were detected at that time. On July 24, 1938, at 8 LX., she experiencved sharp cramplike pains that began five minutes after coitus. These pains were mostly in the right lower quadrant, but at noon their location shifted to the region of the naval, and later that day consistetl of a dull pain and soreness in the epigastrium. The patient was admitted to the hospital at 2 A.M., on July 23, 1938, with a trmperature of 100° F., pulse 120, of good quality, and respirations 24. The epigastric pains became more severe and she had some pain referred to both should~~rs. The respirations soon became rapid (44 per minute), the breath soumls were diminished in the right lower portion of the thorax, and it hurt the pntirnt to breathe ,tlceply. One iumlw~~ of the midenl staff thought that moist r$les were present anteriorly. The ahdomen was difiicult to palpate due to muscular rigidity. Thew was a mass originating from the pelvis that reached the level of the nayal hut WIS rtlostl,v to the left of the midline. Fetal heart tones could he heard. l’aginal rsun~ination rrvealrtl a long rather narron ronical soft cervix. It was tliffitult to ~1eWrminc by binianual palpation if the mass felt through the abdomen consisted of an intrauterine pregnancy that was drviatetl to the left, or whether the uterus, in view 01’ a c,ervis being disproportionate in size to the entire mass, was separated from it. 1’11~ red count mas 3$50,000 late in the morning. A diagnosis was deferred until the chest could he s-raved. This was reported that afternoon to be negative. The cgondition of the patient was good; therefore, she was placed under close observat,ion. Il~n~\.pv~r, when a repeated red cell count that evening showed a drop to 3,51)O,OOO, it was (lecided to open the abdomen. WC felt certain that we mere dealing with some form of ectopic pregnancy. A preoperative diagnosis of interstitial pregnancy XT-as made purely through the clinical impression gained by the elimination of other related possibilities. Palpatory find ings gave the impression that the pregnanc’y XV:LS not in the endometrial cavity. Intrauterine pregnancy was not consideretl because the cervix did not appear to be proportionate in size to a uterus of five nlontlw ’ gestation. Tubal pregnancy \vi’s excluded because of the rarity of such advanwtl gestation in the tubes. Abdominal pregnancy was considered, therefore, to 1~ the only other possibility, but was not favored because the mass appeared to be too closely identified with the uterus itself. At operation there was a moderate amount of free blood in the peritoneal cavity. The pregnancy was in the left uterine cornu and was unruptured. The left round ligament was at a higher lrvel than the right one, and inferior and lateral to thr emerged frorrl site that contained the fetal sac. The left tube, which was normal, the ride and inferior to the left angle. There was a small perforation on the posterior aspect of the uterine horu from which the patient was bleeding. In attempting to elerate the uterus to plnw clumps on tlw broad ligament for its amputation, the contents of the left uterine cornu began to rupture. This phenomenon consisted of a slow expression of the fetus in its amniotic sac which began at the point of *]‘resented
at R meeting.
of the Chicago
(:l-necological 3 I-1i
Society,
December
16, 1938.
KOl?AK
:
I?;TE1RSTITIAT,
PREGSANC’Y
3;
perforation. The process was rather slow and progressive and could not he checked, hut when the fetal sac and placental remnants were separated and removed from the site of their implantation, the left uterine cornu had the appearance of a strut,ture that had literally been exploded. The bleeding became profuse and the uterus was amputated supracervically. Transfusion of WI C.C. of blood was started as fht~ abdomen mas being closed. The recovery was uneventful and the patient was Ilis~~hnrgrd from the hospital fourteen days postoperatively.
Fig. L-Anterior view of uterus showing the left round ligament (A). at a higher level than that on the right side, (B), and where the uterus was amputated (C). TO the right the fetus is shown enclosed in the amniotic sac.
Fig.
2.--Posterior
view completely
of uterus showing the from the endometrial
ruptured cavity
(to
left uterine the right).
:rnfilc
st~~raled
The specimen consisted of the uterus in which t,he left broad ligament attachment The appendages were therefore higbet was much longer than that of the right side. on that side. The cavity that contained the fetal sac was completely separated by a very thin septum from the ut,erine caritv. The fetus measured 16 cm. from heall to rump.
PREGNANCY”
GESTATION, WITH AN OBRERVATIOK OF THE YHE~NOMENON OF RU~TVKE AT TIN%: TIME 0~ OPERATION
T
HE diagnosis of this type of tubal pregnancy before rupture is most difficult to make. Unless one has this condition in mind together with its criteria, the diagnosis map not he clear even at the tinie of operation, particularly if rupture has not occurred. ‘I’. K., 2i years 0111, caolorerl, married uint~ >-ears, 11:1(1 not Iwcn able to bec*onw pregnant. She last menstruated on Maw11 1, 19%. There were no unusual symptoms aside from right lower quadrant ashes which were worse at the time of her menstrual molimina. She was first seen in the prenatal czlinic of the Cook County Hospital on June 27, 19.38 and no abnormal findings were detected at that time. On July 24, 1938, at 8 LX., she experiencved sharp cramplike pains that began five minutes after coitus. These pains were mostly in the right lower quadrant, but at noon their location shifted to the region of the naval, and later that day consistetl of a dull pain and soreness in the epigastrium. The patient was admitted to the hospital at 2 A.M., on July 23, 1938, with a trmperature of 100° F., pulse 120, of good quality, and respirations 24. The epigastric pains became more severe and she had some pain referred to both should~~rs. The respirations soon became rapid (44 per minute), the breath soumls were diminished in the right lower portion of the thorax, and it hurt the pntirnt to breathe ,tlceply. One iumlw~~ of the midenl staff thought that moist r$les were present anteriorly. The ahdomen was difiicult to palpate due to muscular rigidity. Thew was a mass originating from the pelvis that reached the level of the nayal hut WIS rtlostl,v to the left of the midline. Fetal heart tones could he heard. l’aginal rsun~ination rrvealrtl a long rather narron ronical soft cervix. It was tliffitult to ~1eWrminc by binianual palpation if the mass felt through the abdomen consisted of an intrauterine pregnancy that was drviatetl to the left, or whether the uterus, in view 01’ a c,ervis being disproportionate in size to the entire mass, was separated from it. 1’11~ red count mas 3$50,000 late in the morning. A diagnosis was deferred until the chest could he s-raved. This was reported that afternoon to be negative. The cgondition of the patient was good; therefore, she was placed under close observat,ion. Il~n~\.pv~r, when a repeated red cell count that evening showed a drop to 3,51)O,OOO, it was (lecided to open the abdomen. WC felt certain that we mere dealing with some form of ectopic pregnancy. A preoperative diagnosis of interstitial pregnancy XT-as made purely through the clinical impression gained by the elimination of other related possibilities. Palpatory find ings gave the impression that the pregnanc’y XV:LS not in the endometrial cavity. Intrauterine pregnancy was not consideretl because the cervix did not appear to be proportionate in size to a uterus of five nlontlw ’ gestation. Tubal pregnancy \vi’s excluded because of the rarity of such advanwtl gestation in the tubes. Abdominal pregnancy was considered, therefore, to 1~ the only other possibility, but was not favored because the mass appeared to be too closely identified with the uterus itself. At operation there was a moderate amount of free blood in the peritoneal cavity. The pregnancy was in the left uterine cornu and was unruptured. The left round ligament was at a higher lrvel than the right one, and inferior and lateral to thr emerged frorrl site that contained the fetal sac. The left tube, which was normal, the ride and inferior to the left angle. There was a small perforation on the posterior aspect of the uterine horu from which the patient was bleeding. In attempting to elerate the uterus to plnw clumps on tlw broad ligament for its amputation, the contents of the left uterine cornu began to rupture. This phenomenon consisted of a slow expression of the fetus in its amniotic sac which began at the point of *]‘resented
at R meeting.
of the Chicago
(:l-necological 3 I-1i
Society,
December
16, 1938.
KOl?AK
:
I?;TE1RSTITIAT,
PREGSANC’Y
3;
perforation. The process was rather slow and progressive and could not he checked, hut when the fetal sac and placental remnants were separated and removed from the site of their implantation, the left uterine cornu had the appearance of a strut,ture that had literally been exploded. The bleeding became profuse and the uterus was amputated supracervically. Transfusion of WI C.C. of blood was started as fht~ abdomen mas being closed. The recovery was uneventful and the patient was Ilis~~hnrgrd from the hospital fourteen days postoperatively.
Fig. L-Anterior view of uterus showing the left round ligament (A). at a higher level than that on the right side, (B), and where the uterus was amputated (C). TO the right the fetus is shown enclosed in the amniotic sac.
Fig.
2.--Posterior
view completely
of uterus showing the from the endometrial
ruptured cavity
(to
left uterine the right).
:rnfilc
st~~raled
The specimen consisted of the uterus in which t,he left broad ligament attachment The appendages were therefore higbet was much longer than that of the right side. on that side. The cavity that contained the fetal sac was completely separated by a very thin septum from the ut,erine caritv. The fetus measured 16 cm. from heall to rump.