- Email: [email protected]
Successful Use of Progesterone in a Case of Repeated Spontaneous Abortion
SUCCESSFUL USE OF PROGESTERONE IN A CASE REPEATED SPONTANEOUS ABOR.TION A. CHARLES
POSNER,
M.D., F.A.C.S.,
AND PHILIP
C
G. D., married
the
a 36-year-old, twelve years,
Obstetvic
fkr~ice
SECHZF,R,
M.D.,
N. ‘I’.
NEW YORK, (From
H.
OF
of
the
Brana
Hospital)
Russian Jewish housewife, Bronx Hospital No. complained of inability to carry her pregnancies
109937, to term.
There was no familial history of hereditary illnesses, sterility, or habitual abortion. Both the patient and her husband have siblings married and with children. One of the patient’s sisters has 12 children. The patient’s past history was noncontributory, except for typhoid fever and pertussis and for the privations she suffered during and after the First World War in Europe. The menarche occurred at the age of sixteen; the periods lasted from one to two days and the flow was slight. Until her marriage, the patient experienced severe dysmenorrhea. Venereal diseases were denied by name, symptoms, and laboratory tests. The patient was married in the United States in June, 1927. She and her husband were well-matched emotionally and intellectually and were anxious to have children. The patient’s first spontaneous abortion occurred in August, 1927, after one missed menstrual period. In November of the same year there followed another spontaneous abortion at three months. It was suggested that “straightening the womb” would aid pregnancy; this was done without external scars in February, 1928. The operation was futile, however, as the patient again ab0rte.d spontaneously in August, 1928, at three months. For the next few months the patient attended an outpatient department, where she says that many tests, including the Huhner and Rubin tests, were done, with normal results. By this time, the lack of a child in t,he family had become the source of much marital bickering and discussion as to which partner was at fault. In fact, there were a number of temporary separations. The patient became pregnant again in the spring of 1929. She spent the next five months in bed, as near to complete rest as possible. In October she aborted twins. There was a septic postabortal course, for which a curettage was performed. She developed a severe urinary infection and was under treatment for the remainder of the year in another outpatient .department. An abortion in the second month occurred in October, 1931, following which a curettage was done. January, 1932, brought a two-and-one-half-month abortion. In September, 1932, after a long period of bed rest, the patient aborted six month twins. And finally in May, 1935, there was an abortion at three months. The writers were consulted in June, 1939. At that time the emotional and psychologic marital disturbances were marked. The patient had been told by other physicians that persistence in attempts to bear children would be futile and even dangerous. The general physical examination was essentially negative. The patient was obese, weighing 160 pounds and measuring 603/4 inches in height. Her uterus was retroverted and the cervix small. In the absence of any serious pathologic conditions and because of the urgent desire for a child, the patient was told that she might become pregnant at any time and wae advised to take wheat germ oil capsules and to rest in bed as much as possible. She had a scant periad in July; early in September a Friedman test confirmed the diagnosis of pregnancy. At the end of September, exactly three months after the last menstrual period, the patient called us in because of vaginal hemorrhage and intermittent backache. Vaginal examination was not performed. An initial dose of one international unit of progesterone was given immediately, followed by one-half unit dose twice weekly. 324
POSNER AND SECHZER:
PROGESTERONE IN ABORTION
325
The vaginal bleeding quickly decreased and stopped altoget,her at the end of the week. The one-half unit dose was continued semiweekly for eighteen injections, after which one unit weekly was administered until the last month of pregnancy. At four-week intervals, corresponding to the time when the regular menstrual period would have come, an added injection was given in the middIe of the week. The patient continued to rest in bed. She took wheat germ oil capsules three times a day and occasional half grain phenobarbital and calcium lactate tablets, and observed a 1500 C.C. fluid salt-poor diet. Under this regime, gestation proceeded satisfactorily. The patient volunteered that she had never’ felt so well in her previous pregnancies as in this one. In other pregnancies she had suffered dysmenorrhea-like pain; now she felt quiet and perfectly relaxed. The blood pressure and urinalyses remained normal. The Wassermann test was negative. Fetal life was felt in November; the fetal heart was first hear,d in January, 1940. Mild toxemia symptoms, slight edema and a faint trace of albumin, were noticed in March; restriction of fluids and salt was enforced. A troublesome hemangioma developed on the left thumb. Despite cauterization, it bled considerably, and irradiation was required in the postpartum period. On April 8, 1940, the patient began to pass large amounts of amniotic fluid. She was admitted to the Bronx Hospital, and the drainage ceased after five clays She spent the last month of pregnancy in bed at the hospital; during this time no endocrine preparations were given. The membranes ruptured and labor started spontaneously on May 7. Roentgenograms revealed the pelvis to be ample and the baby of normal size. Little progress, however, was noted. The cervix was thick and hard and did not dilate beyond two fingers. The head, which was in the left occiput posterior position, did not engage. Because of these indications, a low cervical cesarean section was performed on May 8, after a trial labor of twenty-four hours; a normal 6 pound 8 ounce girl was delivered. The mother’s blood count on the day of delivery was: red blood cells 3.90 pie., hemoglobin 9.6 Gm., or 66 per cent (Sahli), white blood cells 12,800; differential: polymorphonuclears 89 per cent, stab cells 1 per cent, lymphocytes 7 per cent, monocytes 3 per cent. The postoperative course was uneventful. On the day of discharge, May 22, fourteen days after birth, the baby weighed 6 pounds 14 ounces. Within the reappearance of menstruation four months post partum, a bizarre sequel of the hormone injections manifested itself. The arms and buttoeks, the sites of injection, became swollen, painful, tender, and hemorrhagic for the duration of the menstrual period. Up to the present writing, this has recurred four times. The reaction at the sites of injection of the hormone, coincident with the menses, is probably a sensitization phenomenon. In our study of reported cases, we have found no mention of such a sequel to progesterone therapy. 51 EAST 90TH STREET 981
Fox
STREET
H. : Signiiloance f. GynKk. 167: 622, 1938.
Guggisberg,
and
Prevention
of Conga&al
Shruma,
Arch.
The pathology of congenital struma is described at length and its relationship to maternal hypothyroidism and endemic goiter is discussed. In 1925, 53 per cent of -babies born at the Bern Frauenklinik showed evidences of struma. The a&&istration of iodine to the pregnant women throughout pregnancy during 1937 wsaftad in a reduction to 30 per cent. This reduction in congenital goiter depends solely upon iodine administration and is not related to maternal health. The author believes that endemic. goiter could finally be eradicated and cretinism reduced to a minimum if iodine administration is continued not only throughout intrauterine life but also during childhood and maturity in order that a second generation may thus be produced under iodine therapy. RALPH A. axEi.
POSNER,
M.D., F.A.C.S.,
AND PHILIP
C
G. D., married
the
a 36-year-old, twelve years,
Obstetvic
fkr~ice
SECHZF,R,
M.D.,
N. ‘I’.
NEW YORK, (From
H.
OF
of
the
Brana
Hospital)
Russian Jewish housewife, Bronx Hospital No. complained of inability to carry her pregnancies
109937, to term.
There was no familial history of hereditary illnesses, sterility, or habitual abortion. Both the patient and her husband have siblings married and with children. One of the patient’s sisters has 12 children. The patient’s past history was noncontributory, except for typhoid fever and pertussis and for the privations she suffered during and after the First World War in Europe. The menarche occurred at the age of sixteen; the periods lasted from one to two days and the flow was slight. Until her marriage, the patient experienced severe dysmenorrhea. Venereal diseases were denied by name, symptoms, and laboratory tests. The patient was married in the United States in June, 1927. She and her husband were well-matched emotionally and intellectually and were anxious to have children. The patient’s first spontaneous abortion occurred in August, 1927, after one missed menstrual period. In November of the same year there followed another spontaneous abortion at three months. It was suggested that “straightening the womb” would aid pregnancy; this was done without external scars in February, 1928. The operation was futile, however, as the patient again ab0rte.d spontaneously in August, 1928, at three months. For the next few months the patient attended an outpatient department, where she says that many tests, including the Huhner and Rubin tests, were done, with normal results. By this time, the lack of a child in t,he family had become the source of much marital bickering and discussion as to which partner was at fault. In fact, there were a number of temporary separations. The patient became pregnant again in the spring of 1929. She spent the next five months in bed, as near to complete rest as possible. In October she aborted twins. There was a septic postabortal course, for which a curettage was performed. She developed a severe urinary infection and was under treatment for the remainder of the year in another outpatient .department. An abortion in the second month occurred in October, 1931, following which a curettage was done. January, 1932, brought a two-and-one-half-month abortion. In September, 1932, after a long period of bed rest, the patient aborted six month twins. And finally in May, 1935, there was an abortion at three months. The writers were consulted in June, 1939. At that time the emotional and psychologic marital disturbances were marked. The patient had been told by other physicians that persistence in attempts to bear children would be futile and even dangerous. The general physical examination was essentially negative. The patient was obese, weighing 160 pounds and measuring 603/4 inches in height. Her uterus was retroverted and the cervix small. In the absence of any serious pathologic conditions and because of the urgent desire for a child, the patient was told that she might become pregnant at any time and wae advised to take wheat germ oil capsules and to rest in bed as much as possible. She had a scant periad in July; early in September a Friedman test confirmed the diagnosis of pregnancy. At the end of September, exactly three months after the last menstrual period, the patient called us in because of vaginal hemorrhage and intermittent backache. Vaginal examination was not performed. An initial dose of one international unit of progesterone was given immediately, followed by one-half unit dose twice weekly. 324
POSNER AND SECHZER:
PROGESTERONE IN ABORTION
325
The vaginal bleeding quickly decreased and stopped altoget,her at the end of the week. The one-half unit dose was continued semiweekly for eighteen injections, after which one unit weekly was administered until the last month of pregnancy. At four-week intervals, corresponding to the time when the regular menstrual period would have come, an added injection was given in the middIe of the week. The patient continued to rest in bed. She took wheat germ oil capsules three times a day and occasional half grain phenobarbital and calcium lactate tablets, and observed a 1500 C.C. fluid salt-poor diet. Under this regime, gestation proceeded satisfactorily. The patient volunteered that she had never’ felt so well in her previous pregnancies as in this one. In other pregnancies she had suffered dysmenorrhea-like pain; now she felt quiet and perfectly relaxed. The blood pressure and urinalyses remained normal. The Wassermann test was negative. Fetal life was felt in November; the fetal heart was first hear,d in January, 1940. Mild toxemia symptoms, slight edema and a faint trace of albumin, were noticed in March; restriction of fluids and salt was enforced. A troublesome hemangioma developed on the left thumb. Despite cauterization, it bled considerably, and irradiation was required in the postpartum period. On April 8, 1940, the patient began to pass large amounts of amniotic fluid. She was admitted to the Bronx Hospital, and the drainage ceased after five clays She spent the last month of pregnancy in bed at the hospital; during this time no endocrine preparations were given. The membranes ruptured and labor started spontaneously on May 7. Roentgenograms revealed the pelvis to be ample and the baby of normal size. Little progress, however, was noted. The cervix was thick and hard and did not dilate beyond two fingers. The head, which was in the left occiput posterior position, did not engage. Because of these indications, a low cervical cesarean section was performed on May 8, after a trial labor of twenty-four hours; a normal 6 pound 8 ounce girl was delivered. The mother’s blood count on the day of delivery was: red blood cells 3.90 pie., hemoglobin 9.6 Gm., or 66 per cent (Sahli), white blood cells 12,800; differential: polymorphonuclears 89 per cent, stab cells 1 per cent, lymphocytes 7 per cent, monocytes 3 per cent. The postoperative course was uneventful. On the day of discharge, May 22, fourteen days after birth, the baby weighed 6 pounds 14 ounces. Within the reappearance of menstruation four months post partum, a bizarre sequel of the hormone injections manifested itself. The arms and buttoeks, the sites of injection, became swollen, painful, tender, and hemorrhagic for the duration of the menstrual period. Up to the present writing, this has recurred four times. The reaction at the sites of injection of the hormone, coincident with the menses, is probably a sensitization phenomenon. In our study of reported cases, we have found no mention of such a sequel to progesterone therapy. 51 EAST 90TH STREET 981
Fox
STREET
H. : Signiiloance f. GynKk. 167: 622, 1938.
Guggisberg,
and
Prevention
of Conga&al
Shruma,
Arch.
The pathology of congenital struma is described at length and its relationship to maternal hypothyroidism and endemic goiter is discussed. In 1925, 53 per cent of -babies born at the Bern Frauenklinik showed evidences of struma. The a&&istration of iodine to the pregnant women throughout pregnancy during 1937 wsaftad in a reduction to 30 per cent. This reduction in congenital goiter depends solely upon iodine administration and is not related to maternal health. The author believes that endemic. goiter could finally be eradicated and cretinism reduced to a minimum if iodine administration is continued not only throughout intrauterine life but also during childhood and maturity in order that a second generation may thus be produced under iodine therapy. RALPH A. axEi.