Abdominal pregnancy at Charity Hospital in New Orleans

volume 84

number 10

November 15, 1962

American Journal of

Obstetrics and Gynecology

Transactions of the Eighty-fifth Annual Meeting of the American Gynecological Society Continued

Abdominal pregnancy at Charity Hospital in New Orleans WOODARD D. BEACHAM, M.D. WILLIAM C. HERNQUIST, M.D.* DAN W. BEACHAM, M.D. HERMAN D. WEBSTER, M.D. New Orleans, Louisiana

his points that "may prove of value to future operators" he stated, "Had an effort at removal of the placenta been made, I think that, for reasons already assigned, disastrous consequences would have ensued. Had the abdominal wound been allowed to close, by first intention, I think that the imprisonment of a putrid placenta would inevitably have created septic poisoning, with its unfortunate train of consequences." In his 1955 address, President Philip Williams173 reviewed Samuel Bard's Compendium of the Theory and Practice of .J!idwiferJ', stating. "In an extended discussion of extrauterine pregnancy Bard denied the possibility of a primary abdominal pregnancy. He cites here a correct preoperative diagnosis of an extrauterine pregnancy, operation, and recovery in the

A T T H E inaugural meeting of the American Gynecological Society Gaillard Thomas157 presented a paper entitled "Report of a Case of Abdominal Pregnancy Treated by Laparotomy." His patient survived. Among

From the Department of Obstetrics and Gynecology, Tulane University School of Medicine. The opinions expressed in this article are those of the authors and do not necessarily reflect those of the Department of Defense or the Department of the Air Force. Presenied at the Eighf:y-fifih Annual Meeting of the American Gynecological Society, Hot Springs, Virginia, May 31-]une 2, 1962. *Colonel Hernquist is now Deputy Commander at USAF Hospital WrightPatterson, J-Vright-Patterson Air Force Base, Ohio.

1257

1258

_\o\clflbt·r 15. l~lb~ \m . .I. Oh;l. & ( ;ylll·c.

Beacham et al.

practice of his father, John Bard, in 1759." The history of abdominocyesis is very fascinating, but brevity demands that we refer the reader to disquisitions by Schurnann/38 Ricci, 130 Jarcho, 81 King, 89 and others. In this publication we shall refer to the cases of abdominal pregnancy at Charity Hospital in New Orleans from July 1, 1937.. through June 30, 1945, as Series A and those managed there from July 1, 1945 to Jan. 1, 1962, as Series B. As the result of finding 2 case records which were not available at the time of preparation of the articieH for the December, 1946, Obstetrical and Gynecological Survey, Series A now consists of 22 patients, 2 of whom died. As shown by Table I, in the span of 2312 years there has been a total of 65 cases of which only 3 were in white patients. This substantiates our opinion that many nonwhite persons in the vicinity of New Orleans do not realize the importance of seeking medical advice regarding signs or symptoms compatible with tubal abortion and the "milder forms" of tubal rupture. All of the New Orleans Charity Hospital cases with the exception of one in Serit's B have been of the secondary type. Never have we said that the primary type cannot occur but we have pointed out that it is very rare. Cavanagh 31 discussed the subject in 1958. To us abdominocyesis means pregnancy within the peritoneal cavity; consequently, we have not included cases of intraligamentous or advanced tubal pregnancy in either of the New Orleans Charity Hospital series or the reported series which we have designated with the letters Y and Z. The latter consists of those cases reported since 1945 in the English language periodicals which have been available to us. Series A and B include cases managed on the Tulane, Louisiana State University, and Independent Units. The last was abolished June 30, 1961. There have been 56 operators. One of us (W. D. B.) has had the opportunity to see the patients admitted to the Tulane Service.

Incidence

Occurrence at the Charity Hospital in New Orleans is depicted in Table I. During the time of 219, 16+ deliveries I including stillbirths) there have been 65 cases or l per 3.371.75. Crawford and Ward'" found an incidence of 1:3.161 deliveries at the Charity Hospital in Shreveport, Louisiana, during an 8 year period ( 19+9 to 1956). Obviously there are factors which influence the incidence. If all patients everywhere received good obstetric care there would be no instances of secondary abdominal pregnancy. Race

It has already been stated that of the New Orleans Charity Hospital combined series of 65 patients only 3 have been white. In the literature the race was not mentioned in many instances but in 553 cases it was reported to be nonwhite in 326. In comparing Series Z with Y in Table II one sees that the number of Negroes has more than doubled. In those two series there were 47 persons who were members of neither the Caucasian nor the Negro race. Douglass and Kohn/ 9 in an article regarding 26 cases of "advanced uterine pregnancy that could be found in Baltimore during the period from January 1, 1920, through December 31, 1944," stated that the condition was sixteen times more frequent in the Negro than in the Caucasian race. Age

In considering the age incidence it should be pointed out that one of the cases added to Series A was in a 42-year-old patient. In Series B the greatest increase has been in the 20 to 24 year age group. The age of the patient with a lithopedion in this series was 32 years, which contrasts sharply to Series Y in which lithopedions were found in persons of 55, 64, 90, and 94 years old. The youngest patient in Series Z was 17 years of age. 110 The eldest was aged 66 years and the fetal mass was said to have felt like a sac of golf tees. 68

Volume 84 Number 10

Abdominal pregnancy

Table I. Abdominocyesis at New Orleans Charity Hospital Period Cases Deliveries Negro White

Series A

Series B

7/1/37 thru 6/30/45 22 ( 1 white) 41,634 30,215 11,419

7/1/45 thru 12/31/61 43 (2 white) 177,530 154,772 22,758

Gravidity

There is no designation of gravidity in many cases in the literature. However, as shown in Table IV, a considerable majority of the patients have been previously pregnant. As expected, the incidence is indirectly proportional to the gravidity status. One patient in Series B was a quattuordecimigravida. Previous pregnancies

While only about one third of the patients in Series A gave a history of having had previous gestations result in term deliveries only, the fraction increased to one half in Series B. In the latter, 6 patients had each experienced 3 term deliveries and one abortion; one had one term pregnancy and 2 abortions; another had 8 deliveries at term and 5 abortions; and one patient gave a history of 3 spontaneous abortions. As shown in Table V, there was one instance of a term delivery and later an ectopic pregnancy. One of the 13 primigravidas in Series B had been married for 17 years. In Series Z long periods of infertility have been mentioned by several authors. 34 • 52 142 180 • • Unfortunately, there was no statement regarding the character of previous gestations in 102 cases in that series. There were two instances of patients with two successive abdominal pregnancies. 71 • 98 Diagnosis

As was emphasized in an earlier study/ 4 the importance of a carefully obtained history with the possibility of abdominocyesis being kept in mind, is exceedingly important. Thorough examination of the patient is also

1259

necessary for accurate diagnosis. In this article it would have been simpler to have omitted cases of less than 28 weeks, but early cases have been included to emphasize the necessity for diagnosis and definitive therapy. In our experience, abdominal tenderness and pain on uterine motion have been the most consistent findings. In many cases an extrauterine mass was palpable but in some cases it was not felt due to obesity, intestinal distention, or some other complicating factor. When palpable, the uterus has usually been smaller than anticipated for the suspected duration of gestation. Diagnosis after twentieth week. The history in these cases is often rewarding in that the patient reports abnormal fetal movements which usually become more painful as cyesis progresses. They are apt to have symptoms which have been frequently regarded as being of gastrointestinal or biliary origin. The patient may complain of "the baby being high in the stomach." In the cases in the literature and of those managed at Charity Hospital too many have been categorized as having "false labor" without the examiner considering the possibility of abdominocyesis. Attempted inductions of labor have occurred and some of the cases should be labeled tragedies of errors. The high or displaced cervix uteri has been a frequent finding in advanced abdominocyesis at the Charity Hospital and the absence of cervical effacement in patients who thought they were in labor has been impressive. In addition to the other diagnostic findings which we have previ· ously discussed, 14 it should be said that Dixon and Stewart47 have stressed the value of a maternal vascular souffle. Oxytocic stimulation of the uterus has been found to be useful in cases of suspected abdominocyesis. In 1956, Vasicka and Grable161 reviewed the literature and reported 2 cases of simultaneous extrauterine and intrauterine pregnancies progressing to viability. In one of their cases both infants and the mother lived. Since their article, instances of simul-

Suvt·wlwr l :}, 191)2 J, OI"L & f:yrlf'r,

1260 Beacham et al.

,\m,

Table II. Racial incidence* ··~·-·•--.-~~

cases

Series Z White Negro Other *Unfortunately~

17:\ 81 21

Total

54 198 26

230

21 0

----

-tl II

:Hl .f7

··-------·--··---"

----

the- race ,,a.., not nwntionrd in a Jar.l;fe per cent of the reports.

Table III. Age incidence cases

Series Z

Age

15-19 20-24 25-29 :10-34 :)5-39 -W

Series B

Total

33

2

1 10

13

33 61

6

11

162

67

84 94

67

45

5

124

21

19

I

12 7 2

4

taneous abdominocyesis and uterine gestation have been reported by Chapman, 35 Drury, 51 Irwin, 78 and Kariks. 84 Cases of abdominocyesis twins have been recorded by Billington, "8 Rangala, m and Todes. 159 Abdominocyesis radiography. If the x-ray film shows evidence of an unusual lie of the fetus, the likelihood of advanced extrauterine pregnancy must be considered. In cases of abdominocyesis the fetus is most often in the transverse or oblique lie. Maternal intestinal gaseous shadows intermingled with fetal parts may be seen. The absence of a uterine shadow around the fetus is diagnostic if the films are of proper quality. In some cases x-ray technique has been good but the films cannot be so classified because of intestinal distention, etc. Lateral views are particularly valuable when they show fetal parts overshadowing the maternal vertebrae. One must not forget the possibility of sacculation of the uterus, rare though it is. A discussion of the possible attitudes of abdominal fetuses would be interesting but lengthy. Suffice it to say that each fetus has its own problem of adaptation. This also applies to intrauterine pregnancies in malformed uteri, some tumor-harboring uteri_, and in certain cases of placenta previa. As previously stated 14 we have found

78 180 43

hysterography to be valuable in confirming the diagnosis of abdominocyesis, but we again caution against its indiscriminate use. Cavanagh, Gilson, and Powe 33 evaluated SO cases of isotopic placentography but none showed abdominocyesis. This procedure is being studied on the L. S. U. Service at Charity Hospital. Coale, Richey, and McGanity 40 discussed placental localization utilizing the intravenous method of aortography. In the May, 1962, GRAY JouRNAL they mention 2 proved cases of abdominal pregnancy. Todes 159 and Nelson and associates 115 have discussed the more direct technique of localization by percutaneous transfemoral retrograde arteriography. We plan to employ this procedure in selected cases inasmuch as preoperative placental opacification would be of inestimable value. The preoperative diagnoses found in 4-7 of the Charity Hospital records are shown in Table VI. Those in the other 5 cases include pregnancy with toxemia, uterine pregnancy versus ectopic, ovarian cyst and possible abdominal pregnancy, pelvic abscess. and transverse lie and acute abdominal conditions in a patient with schizophrenia and pre-eclampsia. One patient was not operated upon. A similar case in which the diagnosis was made post mortem was reported by two different authors. 59 • 163

Abdominal pregnancy 1261

Volume 84 Number 10

Treatment

the quantity actually given should be governed by the amout of blood loss. The incision should be made in such a way as to carefully avoid the placenta if possible. After the sac is opened in its least vascular area the fetus is gingerly removed and the placental attachments cautiously studied, avoiding any traction on the cord or sac which might cause hemorrhage. If the blood supply of the placenta cannot be definitely ligated the organ should be left in situ and the abdominal incision closed without drainage. Packs should be used only if control of hemorrhage demands them. Liquefaction due to placental degeneration must not be mistaken for infection. When in doubt smears and cultures should be made. It goes without saying that if the placenta can be safely removed it should be extirpated. Postoperatively, oxygen, blood, fluids, and electrolytes should be administered as indicated in each case, gastrointestinal and urinary bladder drainage being continued.

We agree with Eastman and Helhnan53 that "immediate operation should be done just as soon as the diagnosis is established" and an adequate supply of compatible Rhhr suitable blood is available. Greenhill67 points out the fact that "through religious beliefs, the patient may demand delay to save the fetus; in this event she is hospitalized to await the operation" but she and her husband must be informed as to the possibilities and probabilities regarding her and the fetus,. and the facilities should be such that valuable time will not be lost if the situation worsens. Preoperative preparation should include careful evaluation of the patient, gastrointestinal decompression with the tube being left in place, an indwelling Foley urethral catheter, emptiness of the rectum and colon, an infusion in progress with a No. 18 gauge needle in a vein, and equipment for intraarterial transfusion within reach. Liters of blood should be immediately available but

Table IV. Gravidity incidence Charity Hospital

Reported cases Gravidity ii iii iv v vi

vii viii ix

Series Y

Series Z

Series A

Series B

69 82 36 26

81

8 6 1

13 6 i 5 6

11

12 9

74

49 22 18 16

1

5 3

8

1

4

0 3

93

57 35 35 15 4 10

4 1

0

0

0 0

Total 171 168

1

Table V. Character of previous gestations cases Series Z

Previous pregnancies Term only Term and abortion Abortion only Term, abortion and ectopic Term and ectopic Ectopic only Abortion and ectopic Not reported as to type Premature labor

7 2 1

22

0

0

0

3

1

0 0

0

0

102 3

4 0

1 0 0 0 0

118 21 28 1

91 34

2

2

1 88 1

19

6 1

1262

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Beacham et al.

.\·:o.

Table VI. Preoperative diagnosis at New Series 21 2 2 2 10 0 0

tj. J~jl)~ Ol»t. & (,vt><·<·

the experience at the Charity Hospital (Table VIII). Three of the Series B patients in whom the placenta was left in situ had operations at the Charity Hospital in New Orleans for its removal after 6, 12., and 14· months respectively. Some of the patients resided at considerable distances from New Orleans and a follow-up study has not been satisfactory. In Series Z placental management was not reported in 10 cases in which death occurred. Eight of these were reported in one article 40 and the other 2 in different publications.81• 163 In the 100 cases in which the placenta was stated to be left in situ 10 of the patients died and 31 had major complications according to the reports. In the same series there were I 7 cases in which the placenta was reported to have been partially removed. Two of these subjects died and 2 are known to have had major complications. Jackson 79 reported a case of choriocarcinoma which developed in a placenta which was left in situ at the time of removal of a 5 pound, 8 ounce stillborn infant from the peritoneal cavity. He quoted Hertig as follows: "The rnore pathologic the pregnancy, the more apt to give rise to true choriocarcinoma.''

Orleans Charity Hospital Series A Abdominal pregnancy 17 Pregnancy and myoma 0 Pregnancy and ovarian cyst 0 Pregnancy with transverse lie 1 Ruptured ectopic pregnancy 1 Dead fetus and toxemia 1 Dead fetus and polyhydramion 1 Uterine myomas with pregnancy versus abdominal pregnancy 0

J

B

2

Vitamins are given parenterally and so are antibacterials if they are indicated. In order to ascertain "the actual presentday management of the placenta in late abdominal pregnancy" Hreshchyshyn, Bogen, and Loughran 75 analyzed 101 cases, including 98 cases collected from original case reports published in the world literature from 1950 to 1957. Thirty-six of their references were not in the English language. They divided the factors determining the management of the placenta into two groups: ( 1) inherent placental factors, namely, location, blood supply, shape, and state of vitality; ( 2) complications present at the time of operation. Of the 82 adequately described cases evaluated for placental location it was intraligamentous in 11 per cent. In the total of 101 cases they found only 2 maternal fatalities, both of which occurred in eases where the placenta was left in situ. As expected, postoperative morbidity was considerably higher when the placenta was left in the abdomen. This has also been

Maternal mortality

One reason that we have not included intraligamentous and advanced tubal pregnancy under the title of abdominocyesis is that the treatment is usually less difficult and the mortality rate is lower in such

Table VII. Age of fetuses cases

Weeks

8-12 12-16 16-20 20-24 24-28 28-32 32-36 36-40

40

Series 9 0 27 0 20 0 44 0 2

B

Series Z 23 23 23 26 14 20 38 102 33

0

14 8 7 0 1 4 6 2

0

I

1 0 8 0 4 0 9

Volume 84 Number 10

Abdomina! pregnancy

1263

Table VIII. Placental management and maternal mortality Reported cases

Charity Hospital Series B

Placenta

Removed completely Partially removed Left in situ Not reported

172 15 61 44

175 17 100 42

cases. For example, 8 of Ware's163 13 cases of late extrauterine pregnancy (after the twenty-eighth week) were of the abdominal type and 4 of these patients died. The first maternal death in Charity Hospital Series A was due to infection. A dead, malformed 6 pound, 9 ounce fetus was obtained post mortem. The second death occurred in the operating room after extraction of a macerated 6Yz months' fetus and a supracervical hysterectomy. The placenta is said to have been attached to the uterus: Hemorrhage was massive. One patient in Series B died during a second laparotomy being done to stop hemorrhage 18 hours after extraction of a living fetus (which had muitipie deformities and died 12 hours later) and removal of the placenta. The patient had severe pre-eclampsia and developed jaundice and anuria. One patient died after extraction of a stillborn 8 months' fetus. The operator's notes state, "We had previously inadvertently cut the edge of the placenta which extended over the midline. Bleeding was furious and in spite of rapid transfusion the patient went into shock." A total of 2,500 mi. of blood was given to no avail. Fetal mortality The fetal mortality in Series Y was about 85 per cent and in Series Z 75 per cent. The figures for Series A and B were 95.5 per cent and 93.1 per cent, respeetively. Table VII shows ages of fetuses in groups. The number 28 weeks or more in the various series was as follows: Y, 46; Z, 193; A, o. J'

~~...1 C.UH..L

nJ..J'

1 'l .LV.

In Series B, 9 babies were delivered alive but 6 died; 34 such instances were reported

17 2 11 3

3

2 10 7

17 1 3

0

18 7 18 0

0 0 1 0

1 0 1 0

m Series z. All of the fetuses in Series A and B had at least one type of malformation although in Series Y and Z normal babies have been reported by several authors. Summary and conclusions Under the title of abdominocyesis we have included the cases in which the fetus was living or evidence that it had lived in the peritoneal cavity. Advanced tubal and intraligamentous gestations have been excluded. Data derived from a study of the case records of 65 patients admitted to the Charity Hospital of Louisiana at New Orleans from July 1, 1937, through Dec. 31, 1961, have been presented. Three hundred and thirty-four cases reported since 1945 in the English language periodicals available to us have been analyzed in tabular form. Prenatal care has as one of its objectives the prevention of abdominocyesis by the recognition and prompt surgical treatment of eccyesis in its primary site. A history compatible with tubal abortion or rupture in a patient who thinks she is pregnant should alert one as to the possibility of abdominocyesis. Abdominal pain and tenderness are consistently present in cases of abdominocyesis. Abnormal lie of the fetus and a high or displaced cervix uteri are two of the most frequent findings in advanced abdominocyesis. Radiography is very valuable in the diagnosis. Laparotomy is indicated when the diagnosis is established, an adequate supply of blood being immediately available. The operative procedure has been briefly discussed, emphasis being placed on the

November 15, 1962 Am. J. Obst. & Gynec,

1264 Beacham et aL

great necessity for prevention of hemorrhage. If the blood supply of the placenta cannot be ligated, the organ should be left in situ. If ligation can be accomplished, the placenta should be removed to prevent complications. Some patients in whom the placenta 1s allowed to remain in situ will require a

REFERENCES*

1. Acosta-Sison, H., and Aragon, G. T.: ]. Philippine :tvf. A. 32; 379, 1956. 2. Adams, J. Q., and Schreier, P. C.: AM. J. OssT. & GYNEC. 73: 680, 1957. 3. Alford, J. M., Jr.: Mississippi Doctor 31: 10, J 953. +. Allen, L. A.: South African M. ]. 28: 131, 1954. 5. Arnold, M. F., and Baker, W. R.: J. M. A. Georgia 41: 484, 1952. 6. Arrington, R. ]., and Williams, D. G.: J. Michigan M. Soc. 49: 805, 1950. 7. Ashworth, F. L.: West African M. J. 7: 63, 1958. 8. Baldwin, W. F.: Obst. & Gynec. 4: 435, 1954. 9. Bansmer, G., and Layton, C. H.: West. ]. Surg. 66: 32, 1958. 10. Barber, J. F., and Rathbun, L. S.: AM. J. 0BST. & GYNEC. 76: 882, 1958. 11. Barrett, M. E.: AM. J. OssT. & GYNEC. 64: 1061, 1952. 12. Barry, A. P., and Hanratty, T.: Irish J. M. Sc. 308: 381, 1951. 13. Bate, C.: Am. J. Surg. 72: 258, 1946. 14. Beacham, W. D., and Beacham, D. W.: Obst. & Gynec. Surv. 1: 777, 1946. 15. Benson, H. R.: Hawaii M. J. 5: 330, 194546. 16. Bcrcovitz, ~I.: Chinese }"{. J. 62: 197, 1944. 17. Bhalla, S. L.: J. Indian M.A. 20: 227, 1951. 18. Billington, W. R., and Goodchild, R. T. S.: Brit. M. J. 2: 787, 1948. 19. Bourgeois, G. A., and Shapiro, M. W.: New England J. Med. 247: 289, 1952. 20. Bowen, G. L.: AM. J. OBsT. & GvNEC. 6i: 455, 1951. 21. Brainard, H. H.: Arizona Med. 8: 39, 1951. 22. Branscomb, L.: AM. J. OBsT. & GYNEC. 54: 874, 1947. 23. Bright, A. S., and Maser, A. H.: Obst. & Gynec. 17: 316, 1961. 24. Broomes, E. L. C.: Am. Pract. & Digest. Treat. 1: 1194, 1950. 25. Broomes, E. L. C.: J. A. M. A. 145: 399, 1951. 26. Brown, W. W., Jr., and Rucker, C.: South. M. J. 40: 905, 1947. *Complete titles of the references will appear in

reprint~~.

subsequent operation for its removal. The old adage "it is better to have a living patient with a placenta in her abdomen than it is to have a dead one whose demise was caused by removal of the placenta" is still true. Abdominocyesis is one of the gravest complications in obstetrics to both baby and mother.

27. Burkons, H. F.: Ohio M. J. 43: 161, 1947. 28. Burleson, R. J., and Bragg, ]. C.: J. A. M. A. i47: 1349, 1951. 29. Campbell, G. L.: J. Kansas M. Soc. 60: 252, 1959. 30. Case Records of the Massachusetts General Hospital: New England J. Med. 235: 277, 1946. 31. Cavanagh, D.: AM. J. OBsT. & GvNEC. 76: 523, 1958. 32. Cavanagh, D., and MacClure, J. G.: Obst. & Gynec. 12: 341, 1958. 33. Cavanagh, D., Gilson, A. ]., and Powe, C. E.: South. M. J. 54: 1340, 1961. 34. Cerone, D. M., and Cicalese, G. T.: Obst. & Gynec. 14: 368, 1959. 35. Chapman, J. D.: j. Internat. Coli. Surgeons 27: 194, 1957. 36. Charlewood, G. P., and Culiner, A. J.: J. Obst. & Gynaec. Brit. Emp. 62: 555, 1955. 37. Chessin, H., and Zussman, L.: Obst. & Gynec. 4: 440, 1954. 38. Clark, J. F. ]., and Bourke, J.: AM. J. 0BST. & GYNEC. 78: 340, 1959. 39. Clark, J. F. J., and Bennett, R. C : AM. J OssT. & GYNEC. 81: 298, 1961. 40. Coale, G. B., Richey, L. E., and McGanity, W. J.: AM. J. OssT. & GYNEC. 83: 1150, 1962. 41. Coodin, P.: Canad. M. A. J. 54: 483, 1946. r _ 'J.r n ..-.:. uraw1ora, J. u., ana vvaru, J. v.: vost. 0< Gynec. 10: 549, 1957. 43. Cross, J. B., Lester, W. M., and McCain, J. R.: AM. J. 0BsT. & GYNEC. 62: 303, 1951. 44. Dabb, G. R.: Brit. M. J. 1: 198, 1947. 45. Delany, A. L.: M. Rec. & Ann. 40: 1342, 1946. 46. Deming, F. S.: AM. J. 0BsT. & GvNEC. 56: 962, 1948. 47. Dixon, H. G., and Stewart, D. B.: Brit. M. J. 2: 1103, 1960. 48. Dorman, D. B.: New England J. Med. 245: 207, 1951. 49. Douglass, L. H., and Kohn, S. C.: West Virginia M. J. 43: 307, 1947. 50. Downing, G. G.: J. Oklahoma M. A. 47: 246, 1954. 51. Drury, K. A.: J. Obst. & Gynaec. Brit. Emp. 67: 455, 1960. 52. Easterling, T. G.: J. Louisiana M. Soc. 105: 21. 1953. A{\

r'1

1

T

T"''o.

'I

1

T

"1: T

....-,.1

•

Abdominal piegnancy 1265

Volume 84 Number 10

53. Eastman, N. J., and Hellman, L. M.: Williams Obstetrics, ed. 12, New York, 1961, Appleton-Century-Crofts, Inc. 54. Elzey, N. D.: West. J. Surg. 56: 410, 1948. 55. Espinola, N. A., and Cajipe, P. M.: J. Philippine M. A. 28: 405, 1952. 56. Farris, C., Kush, A., and Jacobs, A.: AM. J. 0BST. & GYNEC. 68: 1598, 1954. 57. Fejer, E. A. I., and Henry, G. H.: J. Obst. o_ r"~------ n_:...._ " ' - - c::c_ nAn 1nAn oc uyuat:::t:;., JJill, .l:llll!J. JU; 4"t'u, !:7"1'::1.

58. Fernstrom, 1.: Acta radiol. 122: 122, 1955. (Suppl.) 59. Flint, H. E., and Harper, W. F.: West Indian M. J. 3: 185, 1954. 60. Gandy, R. A., and Colmers, R. A.: Connecticut M. J. 13: 630, 1949. 61. Garber, S. T., and Kistner, R. W.: Ohio M. J. 45: 700, 1949. . 62. Giffen, M. B.: J. Obst. & Gynaec. Brit. Emp. 62: 560, 1955. 63. Gilliland, J.: South African M. J. 23: 558, 1949. 64. Gilman, R. A., Schwartz, M., Stephenson, U

.L"'-•)

65. 66. 67. 68. 69. 70. 71. 72.

73. 74. 75.

76.

77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88.

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68: 1187, 1954. Glick, L. J.: Obst. & Gynec. 19: 265, 1962. Graham, D. P., and Curry, C. C.: Obst. & Gynec. 14: 672, 1959. Greenhill, J. P.: Obstetrics, ed. 12, Philadelphia, 1960, W. B. Saunders Company. Hagie, F. E.: J. Indiana M. A. 41: 305, 1948. Harris, M. H.: Surgery 35: 793, 1954. Haynes, D. M., and Nabors, G. C.: South. M. J. 49: 619, 1956. Hazlett, W. H.: Obst. & Gynec. 1: 313, 1953. Hibbard, L. T.: .A.M:. J. 0BST. & GYNEC. 74: 543, 1957. Horner, H., and Harrison, H. E.: U. S. Armed Forces M. J. 6: 181, 1955. Hornstein, S., and Kay, S. A.: Obst. & Gynec. 13: 337, 1959. Hreshchyshyn, M. M., Bogen, B., and Loughran, C. H.: AM. J. OssT. & GYNEc. 81: 302, 1961. Hu, S. T.: Yale J. Biol. Med. 19: 951, 1947. Hunter, R. M., et al.: AM. J. OasT. & GYNEC. 76: 539, 1958. Irwin, H. W.: Obst. & Gynec. 16: 327, 1960. Jackson, R. L.: AM. J. OasT. & GvNEC. 79: 1085, 1960. Jaffe, I. A.: New York J. Med. 57: 1956, 1957. Jarcho, Julius: Am. J. Surg. 77: 273, 1949. Jarrett, J. C.: Ohio M. J. 48: 219, 1952. Jeaffreson, B. L., and Nathan, N. J. S.: J. Obst. & Gynaec. Brit. Emp. 57: 65, 1950. Kariks, J.: M. J. Australia 1: 937, 1960. Karsh, J.: Canad. M. A. J. 60: 70, 1949. Kassebohm, F. A., and Schreiber, M. J.: Harlem Hosp. Bull. 1: 11, 1948. Khare, V. N.: J. Indian M. A. 35: 369, 1960. Kilkenny, G. S., Gutglass, M. F., and Collins, E. G.: Obst. & Gynec. 3: 30, 1954.

89. King, G.: AM. J. OasT. & GYNEC. 67: 712, 1954. 90. Klieger, J. A., and Evrard, J. R.: Wisconsin M. J. 51: 672, 1952. 91. Kobak, A. J., and Laluppa, M. A.: AM. J. 0BST. & GYNEC. 53: 329, 1947. 92. Kroupa, W. E., and Bleicher, J. E.: Obst. & Gynec. 5: 165, 1955. D. H., and Dobrzynski, F. A.: AM. 93. Kushner, T r'\ ___ o_ ,-, ______ c::o_ 1cn 1nAc J•

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lUV,

1::1-ru.

94. Lawlor, M. K.: Proc. Roy. Soc. Med. 39: 575, 1946. 95. Leary, D.: North Carolina M. J. 18: 286, 1957. 96. Lee, A. F.: Northwest Med. 45: 40, 1946. 97. Lesk, L.: Canad. M. A. J. 58: 280, 1948. 98. Lester, W. M., Bartholomew, R. H., and Colvin, W. H.: AM. J. OasT. & GYNEC. 65: 411, 1953. 99. Levine, B., and Blaine, M.: J. Michigan M. Soc. 56: 196, 1957. 100. Logan, F. P.: South African M. J. 23: 415, 1949. 1 n1

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102. Luria, S.: AM. J. OasT. & GYNEC. 57: 1008, 1949. 103. MacGregor, A. S.: Am. J. Surg. 82: 365, 1951. 104. MacKay, E. V.: M. J. Australia 2: 642, 1959. 105. Malkasian, G. D., Jr., Hunter, J. S., Jr., and Remine, W. H.: J. A. M. A. 168: 985, 1958. 106. Marenus, E. B., Planas, M. V., and Silverberg, S. 0.: J. Am. M. Women's A. 13: 187, 1958. ..l 11 ................. U. A ... T 107. 'l...J,.. .............,.,....... t;" nu., ......... a.uu »auu.J., J. OasT. & GYNEC. 72: 1143, 1956. 108. McNulty, J. J.: Obst. & Gynec. 16: 615, 1960. 109. Mendel, E. B., and McCrae, M.: J. lnternat. Col!. Surgeons 24: 457, 1955. 110. Moore, G. H.: M. J. Australia 1: 405, 1948. 111. Morgan, R. G., and Kelvil, N. L.: Brit. M. J. 2: 649, 1945. 112. Mozuffer, S. A.: J. Indian M. A. 15: 378, 1946. 113. Murless, B. C., Goldsmith, J. A., and Gillwald, F. N.: South African M. J. 23: 658, 1949. 114. Mynors, J. M.: J. Obst. & Gynaec. Brit. Emp. 63: 107, 1956. 115. Nelson, J. H., Bernstein, R. L., Huston, J. W., Garcia, N. A., and Gartenlaub, C.: Obst. & Gynec. Surv. 16: 1, 1961. 116. Nethery, R. A.: AM. J. OasT. & GYNEC. 69: 435, 1955. 117. Nokes, J. M., Claiborne, H. A., Jr., Thornton, W. N., Jr., and Yin-Tang, Hsu: Obst. & Gynec. 9: 206, 1957. 118. Owens, W. L.: Obst. & Gynec. 19: 401, 1962. 119. Paranjothy, D.: J. Indian M. A. 33: 372, 1959. 120. Patzkowsky, L. W., Christensen, M. D., and J.l'.l.a.3\.~.lilv.u.,

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1266 Beacham et a!.

121. 122. 123. 12+. 125. 126. 127. 128.

129. 130.

131. 132. 133. 134. 135. 136. 137. 138.

139. 140. 141. 142. 143.

Simon, J. F.: J. Kansas M. Soc. 58: 304, 1957. Pearson, E. A.: West. J. Surg. 58: 712, 1950. Polk, R. C., and Anderson, H. M.: J. Florida M. A. 33: 320, 1946. Posner, A. C., and Beer, M. A.: New York J. Med. 51: 1185, 1951. Quilliam, T. A.: Postgrad. M. J. 24: 482, 1948. Quin 1 N. E.: ]. Roy ..A.rmy !tf. Corps 101: 257, 1955. Rangala, E.: J. Indian M.A. 33: 191, 1959. Reed, C. B.: Texas J. Med. 46: 379, 1950. Reich, S. B., Daughtridge, G. C., and Hunter, H.: AM. J. 0BST. & GYNEC. 68: 727, 1954. Reycraft, J. L., Hill, E. R., and Crosby, W. B.: Ohio M. ]. 46: 666, 1950. Ricci, James V.: The Genealogy of Gynaecology, Philadelphia, 1943, Blakiston Company. Robey, L. R., Spann, C. 0., and Walker, M.: ]. Nat. M. A. 48: 180, 1956. Roddie, T. W.: J. Obst. & Gynaec. Brit. Emp. 64: 913, 1957. Rose, M. J.: J. Florida M. A. 31: 475, 1945. Roy, S. K. S., and Choudhury, N. Roy: J. Indian M. A. 25: 525, 1955. Saltzman, E. ]., McVitty, W. T.: Pennsylvania 1vL j. 55: 1002, 1952. Scadron, E. N.: AM. J. 0BST. & GvNEC. 73: 686, 1957. Schaupp, K. L.: Pacific Coast Soc. Obst. & Gynec. 13: 68, 1946. Schumann, Edward A.: Extra-uterine Pregnancy, New York, 1921, D. Appleton-Century Co. Selman, A. N.: Am. J. Surg. 93: 1036, 1957. Shaw, T. W.: Canad. M.A. J. 63: 597, 1950. Shevade, C. V.: Antiseptic 49: 640, 1952. Siegal, H. A.: ]. Internat. Coli. Surgeons 18: 77, 1952. Siegler, A. M., Zeichner, S., Rubenstein, I., '"T~tt

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Volume 84Number 10

Abdominal pregnancy 1267

Discussion

DR. WILLARD M. ALLEN, St. Louis, Missouri. I have personally observed the course of events in 6 abdominal pregnancies and have operated on 5. One question, of course, is of paramount importance. Once the diagnosis is made with reasonable certainty, is there any greater risk in permitting the patient to approach term than to terminate the pregnancy at once? The chief risk in continuing the pregnancy would be hemorrhage. Because of my interest in placental function, we have deliberately permitted 4 patients to approach term, even though the diagnosis was made as early as 4Y2 months in one patient, at 5 months in another, and at 6Y2 to 7 months in the other 2 patients. In these patients no intra-abdominal hemorrhage occurred between the time of diagnosis and the operation near term (Table I). Another question is of even greater importance. Is it any more dangerous to operate near term than at, say, 5 or 6 months? I do not have any answer to this question since all of our 6 patients were subjected to laparotomy at or near term. However, it would seem to me that the treatment of the placenta would be no more difficult at term than 2 or 3 or 4 months earlier. In 5 of the 6 cases the placenta was not removed at the operation for delivery of the child. Immediate removal of the placenta was carried out in one case (J. D.) because of bleeding during the course of mild manipulation. The patient received 2,000 ml. of blood during the operation and had a smooth convalescence. This placenta, however, was attached primarily to the omentum and the left tube so that removal was relatively easy. In 2 cases the delivery of the child was carried out with

the greatest of ease and the placenta was removed several months later at a second laparotomy, also with no difficulty (M. R. and B. H.). In two other cases (K. S. and J. D.) the re· tained placenta was accompanied by infection, ileus, and a very stormy convalescence. In one (K. S.) the abdomen was reopened 8 weeks post partum and the placenta removed. This was a fairly large intra-abdominal abscess which subsided promptly with drainage. In the other case (J. D.), the incision was reopened but the placenta, which lay just beneath the incision, was not removed because only slight manipulation caused too much bleeding. A pack was inserted to control this. The placenta gradually sloughed out through the incision. The last case ( M. C.) is too incredible to believe. A twin abdominal pregnancy was diagnosed at 5 months. Laparotomy was done during the thirty-sixth week. Two fetuses were removed with ease. The placenta was seen and was presumed to be attached to the posterior wall of the uterus and the posterior peritoneum. Twelve hours later, there was profuse vaginal bleeding and examination showed a placenta protruding through the partially dilated cervix. With moderate traction the placenta was extracted through the cervix, even though we had seen the placenta in the abdomen. Also, the stumps of both umbilical cords were attached to the placenta. To make a long story short, after correction of the blood loss, the abdomen was reopened and the uterus was amputated supravaginally. As expected, there was a 1 inch hole in the posterior wall of the uterus. In this incredible case the uterus must have either ruptured spontaneously or have been traumatically ruptured. The fetuses and a part of the placenta had then herniated through the open-

Table I. Term or near term abdominal pregnancies Fetus Year

Patient

Diagnosis made

Laparatomy

Weight (!!rams)

1947

K. S.

Undiagnosed

40th week

1947 1948

]. D. M. R.

412 months 7 months

1950 1959

]. D. B. H.

Term

1959

M. C.

Livin~?

Fate of placenta

3,000

Yes

39th week 38th week

1,500 1,710

Yes Yes

6Y2 months

41st week 38th week

2,390 2,600

Yes Yes

5 months

36th week

2,150 1,810

Yes Yes

Removed 8 weeks post partum, infection Removed at delivery Removed 4 months post partum Infection, sloughed out Removed 7 months post partum Removed 12 hours after delivery (see text)

r

1268

November 15, 1962 Am. J, Obst. & Gynec.

Beacham et al.

ing and into the peritoneal cavity where the fetuses and part of the placenta thrived for at least 4 months. Since all of our patients survived, it would seem to me that, while the situation is no doubt a dangerous one, it is possible to carry patients to term with abdominal pregnancy. I think also that the placenta had best be left untouched, except in the rarest instance. We have also made an observation regarding fetal survival that may be of some significance (Table II). All babies survived and were healthy when the baby was surrounded by intact membranes and amniotic fluid. All babies died within a few hours after birth when the membranes were found ruptured at the time of laparotomy. These fetuses died of the "respiratory distress syndrome." I had become impressed with this relationship between the status of the membranes and fetal survival before we saw the last case (M. C.) of a twin abdominal pregnancy. In this case we had the rarest kind of good fortune. Here we had a chance to test out the theory. One baby was surrounded by intact membranes and amniotic fluid. This baby cried immediately and had an uneventful neonatal course. The other baby was only partially surrounded by membranes and there was no amniotic fluid. This baby cried immediately but never established normal respiration. Despite every effort the baby died in I 2 hours. These observations again attest to the value of the

amnwtlc fluid and support the concept that babies do inspire some amniotic fluid in utero and that is beneficial to the lungs. I hope subsequent reports on fetal survival in abdominal pregnancy will contain some reference to the status of the membranes at time of laparotomy. We have had one other exceptional case which was neither an abdominal pregnancy nor a tubal pregnancy. The patient was explored at the sixth month of gestation by the surgery service because of severe right-sided abdominal pain. No certain cause for the pain was ascertained, and so, faced with a sixth month pregnancy, a hasty retreat was made. When we discussed the case with them after operation, it seemed to us that the pregnancy was either in the right tube or in the right cornu. Plans were made to open the abdomen near term and deliver the child by whatever means seemed appropriate. However, the patient was readmitted to the hospital because of sudden pain a few days before the planned date for operation. The abdomen was quickly opened. The living fetus was free in the peritoneal cavity with amniotic fluid and some blood. The placenta was attached intramurally in the right cornual area. The fetus was first removed. After the placenta was removed, a finger was passed through the placental site and into the uterine cavity. This then was a case of ruptured cornual pregnancy at term with survival of both the fetus and the mother.

Table II. Relationship of fetal membranes at delivery to fetal survival

Year

Patient

Birth weight (f!rams)

Liveborn

Membranes

s.

3,000 Yes Intact 1,500 Yes Ruptured J.D. 1,710 Yes Ruptured M.R. 2,390 Yes Intact J.D. B. H. 2,600 Yes Ruptured 2,150 Yes Intact M. C. 1,810 Yes Ruptured - · · · · -..·------------'----------_;__ 1947 1947 1948 1950 1959 1959

K.

_..

___

Fate of fetus

Discharged, good condition Died 12 hours Died 4 hours Discharged, good condition Died 2 hours Discharged, good condition Died 18 hours

______________

Table III. Full-term tubal pregnancies

Patient

Diagnosis made before term

Fetal death

Attempted inductions after fetal death

W. P. E. L.

No Yes

Term Term

Yes Yes

Treatment Salpingo-oophorectomy Fetus removed; placenta and tube not removed

Volume 84 Numb.,r 10

My comments on our cases of abdominal pregnancy would not be complete without a remark about the irony of fate (Table III). We have had 3 full-term tubal pregnancies. Only one of these was diagnosed with reasonable certainty prior to fetal death at term. The one diagnosed case was in a woman who refused operation, even to save the baby, because of religious feelings. Only after fetal death and the advent of lactation did she accept the diagnosis. Another physician removed the dead fetus 6 weeks later. The other 2 cases were really diagnosed, apparently as usual, after the fetus had died and repeated attempts to induce labor had failed. DR. RoBERT H. BARTER, Washington, D. C. In speaking of abdominal pregnancy, I am reminded of a patient whom we had at the District of Columbia General Hospital. She had been told by her local doctor that she had a bladder tumor, for the baby was pressing against the bladder, markedly limiting its capacity. Shortly after admission the diagnosis of abdominal pregnancy was made. She was operated upon and the baby was removed in good condition from the broad ligament. When the patient awoke after delivery, she was told that she had a healthy baby. She stated it was not her baby because her doctor had told her that it was a tumor. The placenta had been left in. She became infected and finally sloughed the placenta out. She was in the hospital long enough for the baby to attain considerable poundage. We were ready to discharge the patient about 6 weeks after the d111ivery. When the social worker went to her concerning the baby, she insisted that it was not her baby and that she was not going to take it home; she didn't. We have had only 7 patients with abdominal pregnancy in :recent years. This is a much lower figure than Dr. Beacham presented. We would like to think, inasmuch as this is a condition that is preventable, that perhaps we are making the diagnosis earlier and getting these patients operated upon for ectopic pregnancy. It would be interesting to know how many ectopic pregnancies Dr. Beacham has seen during this same interval. It is also interesting that so few of his patients had had previous ectopic pregnancies. In any large series of ectopic pregnancies, almost invariably 4 per cent of the pa· tients have had a previous ectopic, but this was not borne out in his paper.

Abdominal pregnancy 1269

It would also be interesting to know how many of those patients had been seen by a physician during the course of the abnormal gestation and the diagnosis not made. About 12 per cent of our patients with ruptured ectopic pregnancies had been seen by physicians who failed to make the correct diagnosis. Dr. Beacham has mentioned the transverse lie and the abnormal position of the fetal parts. In the lateral x-ray view the diagnostic feature is the gaseous bubble between the fetus and the abdominal wall which is never seen in an intrauterine pregnancy. There is also overlying of the fetal parts over the vertebral column, another diagnostic roentgenologic sign of abdominal preg· nancy. Abdominal pregnancy represents a real problem. Even in 1962, abdominal and ectopic pregnancies are the fourth greatest cause of maternal death in the United States. The most important consideration is to prevent the patient from developing an abdominal pregnancy because, if she does, her chances of dying increase. DR. EDWARD L. KING, New Orleans, Louisiana. The diagnosis of abdominal pregnancy is frequently missed. The history is of great importance. I have seen cases where the general practitioner has made the diagnosis at 5 or 6 weeks and the physicians at the hospital have missed it and have allowed the patient to go ahead to term. One thing Dr. Beacham mentioned was the painless, symptomless, early rupture or opening of a cesarean scar, particularly of the classical type. I had 3 of those at Charity. The first 2 I did not diagnose and the third I did. Subsequently I had another opening of a cesarean section scar with extrusion of the baby into the abdomen and continued development. That hap· pened to be a bicornuate uterus. I was called in to see the patient; there was considerable abdominal distention. A flat x-ray was made. I called in a general surgeon and the distended loops of bowel that were seen proved to him the presence of partial intestinal obstruction. I was interested in the fact that the baby was lying transversely with the arms and legs down and I knew it was an abdominal pregnancy. We removed the baby and the uterus and the intestinal obstruction was cured. What to do with the placenta is important. In olden days we would wait until the baby had died and then in 5 or 6 weeks would remove the

1270 Beacham et al.

baby and placenta. That is no longer tenable. Now we can proceed more radically as soon as the diagnosis is made, but still it holds true that occasionally we should leave the placenta in. Sometimes it will be absorbed totally in a matter of months. The hemorrhage that occurs with !'arly removal may bP trPmendous and often cannot he controlled. DR. ALLAN C. BARNES, Baltimore, Maryland. I would like to raise two questions, one of them serious: 1. On one of Dr. Beacham's slides there is a patient listed as having abdominal pregnancy with toxemia. This becomes of more than average interest. One would like to know whether the placental implantation was on the back side of the uterus or on the mesentery, for example, and whether the diagnosis of toxemia was carefully rstablished or whether this was essential hypertension. So much of the current thinking about toxemia revolves around ischemia of placental-uterine interface with the production of an unknown substance at that area that, if we have a good clear-cut rclamptogPnic toxemia in a patient who did not have such an interface relationship, we would have a finding of significance. 2. The less serious question is this: I would like to know about the ultimate psychiatric situation with these children. So much of the Freudian concept has to do with our desire to return to the womb. These childrrn, however, have never been in the womb. What will they desire to return to, and will they be subject to totally different psychiatric problems? DR. BEACHAM (Closing). Dr. Allen brought up the matter of the status of the amniotic sac. Our impression is certainly the same as his. If, upon opening the abdomen, it is found that the fetal membranes have ruptured, even though the baby is alive, his or her chances of survival are practically nil. At one of the private institutions in New Orleans there was such a baby

::-lovcml><·r 15, 1Y62 Arn. J. Obst. & Gyncc.

and the obstetrician in charge of that case tells me the baby lived for one month. I am interested in the case in which the placenta was left in the tube. Unless it gets infected, it will probably stay a long time hut, if the patient were in our area, the possibilities of its brcoming infected would be great. Dr. Barter mentioned the importance of a history of previous eccyesis. We re-emphasize the fact that these patit>nts were not all on the Tulane Service but most of them were on the Independent Service and L.S.U. had its shan:. Consequmtly, it could be that some of these patients had had ectopic pregnancies. although the histories did not show this. We wrre pleased to find that the histories were good enough in the cases at Charity Hospital to categorize them as primary or secondary. Most people do not see enough of these cases to really learn about the management from a personal point of view. Dr. Allen is to be congratulated on his series because it is very impressive and dPsPrves recording on its own. I do not think we should let the matter of x-ray overshadowing of fetal parts on the maternal spine be accepted as an absolute diagnostic criterion because this could occur in certain cases of sacculation of the uterus, but I must state that uterine sacculation is more of a rarity than abdorninocyesis. Dr. Barnes mentioned toxemia. I think by the present criteria this particular individual could be said to have pre-eclampsia. She was one patient in whom the placenta was left in situ but she had bleeding subsequent to the laparotomy and, during an attempt to control the bleeding, she died. She had the usual criteria that go with such a diagnosis, and we were impressed in this regard too. Dr. Barnes also mentioned the matter of psychiatric implications. He no doubt saw Owens' article of a patient who had a lithopedion removed from the abdomen and became very upset because the operator had removed her baby from her.