Abdominal pregnancy incarcerated into an umbilical hernia

Abdominal pregnancy incarcerated into an umbilical hernia Case

report

WYNTON ERVIN Los

Angeles,

G. E.

SHAW,

NICHOLS,

M.D. M.D.

California

A B D o M I N A L pregnancy, which is seldom seen except at large clinics, is usually classified into two types, primary and secondary. Although most authors consider abdominal pregnancy secondary to tubal pregnancy, this may be difficult to prove.ZG, “2 32, 42 Evidence of a secondary abdominal pregnancy may be gained by gross inspection of the tube, revealing previous tubal rupture and subsequent reimplantation in the abdomen, or by history alone. Primary abdominal pregnancies that show no evidence of previous tubal implantation are rare. In a review of literature, Tenenblattl” found only 25 cases. The ratio of abdominal pregnancies to total deliveries varies between 1 :2864 to 1 : 15 >o()() >5, 11. 16. 20, 35, 17 the incidence being much greater among Negroes. There is a direct correlation between the incidence of abdominal pregnancy and pelvic inflammatory disease; this is probably more significant since the common administration of antibiotics may relieve symptoms but mask some form of tubal impediment.“, j, I’, 42. 4i A preopera.tive diagnosis of abdominal pregnancy can usually be made if the examining physician has a high index of suspicion, “3 “, 38 which may be aroused by a careful review of the prenatal course.‘? Al-

though there is no classical clinical picture, the most frequent subjective symptoms are amenorrhea, abdominal pain, vaginal bleeding, vomiting, and a history of an abdominal crisis early in pregnancy.‘5, 47 Objective findings may include a uterus too small to be consistent with the length of gestation, unusually loud fetal heart tones, definite displacement of the cervix, high or transverse position of the fetus, inability to palpate the round ligaments, absence of Braxton Hicks contractions, and presence of an extrauterine mass. Procedures that may aid in making the diagnosis include x-ray films of the soft tissues and lateral x-ray films to show intestinal gas shadows anterior to the outline of the fetus’ or the fetal skeleton lying posterior to the maternal spine. X-ray studies may not be helpful during early pregnancy. Colpocentesis or paracentesis is a useful diagnostic aid to determine the presence of intraabdominal blood. Oxytocin*+ I5 has been used in an attempt to stimulate contraction of the uterine musculature. A hysterosaloutlining the contour of the pingogram,‘? uterus and Fallopian tubes has also been used. Once the diagnosis of abdominal pre,qnancy is established, immediate laparotomy is recommended by most authorities because of increased risk of maternal morbidity and mortality as the pregnancy progresses.“, I”. “. 3’s w 44t 47 The over-all fetal salvage is prob-

From the Department of Obstetrics and Gynecology, College of Medical Evangelists, White Memorial Hospital.

72

Volume Number

ably of

84 1

Abdominal

less than

25 per

anomalies

cent.?“,

is

cent,

to ascertain,

number

of cases

the

incidence

15 and 50 per the maternal mortality

41, 47 Although

is difficult

and

between

because

in a series,

of the

it has

been

limited stated

as varying from 15 to 35 per cent.” Management of the placenta is the greatest problem. Special judgment must be used in each particular case. It is mandatory to have an adequate supply of blood available preoperatively. If the placenta is confined to a resectable

region

or

if sufficient

thrombosis

of the placental site has occurred following fetal death, chances of successful removal of the placenta are increased and the danger of severe cations

hemorrhage is decreased,“,

and

postoperative 25-21, 29, 33, 44,

4(‘1,

compli4i

If the placenta is attached to vital organs, spontaneous absorption will usually occur if the placenta remains undisturbed.‘j, ‘r I31 ‘5* 37 Weinberg45 reported one case in which there was a positive pregnancy test 26 days after the fetus was removed and the placenta was left intact. Although the incidence of postoperative morbidity,

abscess

formation,

fistulas,

bowel

obstruction, and other related complications increases considerably when the placenta is left intact, the associated risk is generally less than that of hemorrhage that may occur at attempted removal.l+, e, ‘OS 21-24, “a 31, 34, 38, 39

A 43-year-old Negro housewife, gravida vi, para iv, with 2 abortions, was admitted to the hospital on March 16, 1960, complaining of umbilical pain of 3 days’ duration. She was first seen in the gynecology clinic on Jan. 12, 1960, when her symptoms were amenorrhea, a weight gain of 30 pounds since her last normal menstrual period on Oct. 9, 1959, enlarging abdomen associated with flatulence and constipation for 2 months, and lower abdominal pain and morning nausea for one month. The pain was aggravated by movement, especially something was pulling her walking. She “felt apart on the inside.” An umbilical hernia that had been present for 15 years was noted. Pelvic examination revealed an enlarged uterus consistent with a 3 months’ pregnancy associated with several 2 to 3 cm. fibroids.

pregnancy

incarcerated

into

hernia

73

The

patient’s course between Jan. 12 and 16, 1960, was characterized by constant lower abdominal pain and aching with no acute exacerbation. There was no quickening or uterine bleeding. Three days prior to admission, the patient had persistent umbilical pain that became increasingly worse. She denied vomiting, melena,

March

diarrhea, or urinary symptoms. There were some nausea and anorexia. She had a normal bowel movement on the day of admittance. She had no past history of operations. In 1938, she had been treated for syphilis with bismuth. In 1938, 1944, 1951, and 1952 she had normal deliveries at term. She had 2 spontaneous abortions in 1948. Physical examination revealed an obese 214 pound Negro woman with moderate distress. The blood pressure was 113/80, pulse rate 82, respirations 18, and temperature 99O F. A positive physical finding was a bulging, tender umbilical mass in the region of the hernia. Some erythema was noted on the skin. No fetal heart tones were heard. Bowel sounds were essentially normal. &manual pelvic examination was unsatisfactory because of abdominal tenderness from the hernial mass. The cervix was not displaced. There was more tenderness in the right adnexa

than in the left. Findings

on rectal examination

were normal. The hemoglobin level was 9 Gm., the hematocrit determination 28 volume per cent, the red blood count 3.1 million, and the white blood count 11,000 with 91 per cent polymorphonuclear leukocytes. Urinalysis and serologic test for syphilis were negative. The diagnosis was omentum or small bowel incarcerated into the umbilical hernia. Because of anemia the blood was typed and crossmatched and the patient was taken to the operating room on the day of admittance. A transverse elliptical skin incision was made inferior to the umbilicus. Dissection of the hernial sac revealed an edematous left arm of a macerated 22 cm. fetus incarcerated to the umbilical defect. No fetal membranes were demonstrable. Fine adhesions between the small intestine and fetus were easily freed with blunt dissection. The umbilical cord was tied and cut at its attachment to the placenta and the fetus was removed without difficulty. The placenta was attached to the right Fallopian tube, the ovary, and the immediate parietal peritoneum anteriorly, posteriorly, and laterally; thus the bowel was not involved.

74

Shaw

and

Nichols Am.

Because of thrombosis of the placental site, there was a definite cleavage plane between the placenta and peritoneum. The Fallopian tube and ovary were removed by serially clamping the infundibulopelvic and broad ligaments, thereby allowing complete removal of the placenta. The uterus was twice normal size with several 1 to 2 cm. intramural and subserous fibroids. The left tube and ovary were attached by fine adhesions. Other abdominal organs were normal on inspection and palpation. A Mayo umbilical herniorrhaphy was done. Bleeding was not excessive; the patient received 2 pints of blood during the operation. The postoperative course was uncomplicated. On the second postoperative day the hemoglobin level was 12.2 Cm. The patient had some vaginal spotting on the third and fourth postoperative days and was discharged from the hospital on the seventh day. Follow-up examinations 2 and 5 weeks later showed the abdominal incision healing well and the uterus still slightly enlarged hut with no adnexal masses or tenderness. The pathology report described a 22 cm. female fetus showing comparative macrocephalia, a markedly forward-bulging forehead, and dark purple discoloration of the entire head and upper torso. The left arm was markedly edematous from the elbow downward and showed a C-curve deformation. There was moderate maceration of the integument, especially on the head and left forearm. The tongue protruded from the mouth. Sections of the placental tissue showed large regions of fibrin deposition containing scattered “ghosts” of chorionic villi. Also seen were viable chorionic villi showing an outer layer of syncytial epithelium and scattered Langhans cells along the inner surface of the chorionic cpithelium. A section of ovarian tissue, adherent by fibrosis to dilated Fallopian tube tissue, showed implantation of placental tissue along the outer surface. Another section of ovarian tissue showed a large corpus luteum along the surface of which there was fihrosis contiguous with some necrotic placental tissue. Evidently the placenta was partially implanted on the tube and ovary. There

J. Obst.

was no evidence of malignancy. genesis of this cctopic pregnancy was clear from the microscopic section. tion of the tubal lumen suggested an aalpingitis as a possible initial factor.

July 1. 1962 & Gynec.

The pathonot entirely The dilataold chronic

Comment After

perusal

clude

that

which

an

this

pregnancy hernia.

is the incarcerated not

the

or

or

ity.

If

to

the

fetus

the

probably

could

and

abdomen the

might

was

With

it might right

the

abdominal

been

been

substantiated

have

have adnexal

had a lateral

con-

examination

the

within have

hysterogram,

preoperatively,

analgesia,

diagnosis

umbilical

of abdominal history

palpate

in

abdominal

to an

prenatal

anesthesia

con-

reported

an

diagnosis

diagnosis.

possible

mass

in

considered

the

we

case

a fetus the

was

under

first

was

with

been

literature,

of

retrospect,

sistent

the

arm

Although

pregnancy in

of

x-ray

shown

cav-

suspected, view

the

it by

a

of the

fetal

arm

in

hernia. Fortunately

this

associated and

was

organ.

whether

this

dominal

pregnancy.

It

evidence

indicated,

this

anomalies. to

umbilical

the

site

on

a re-

to prove

or secondary

Certainly

disease.

with

placental

impossible

a primary

microscopic

respect

the

fetus

implanted

seems

was

inflammatory of

of

placenta

sectable

port

a stillborn

thrombosis

the

and

was

there of

As fetus

the had

ab-

was

chronic

gross pelvic

pathology gross

re-

evidence

This

case

is unusual

only

in

fetal

arm

incarcerated

to

the

hernia.

Summary A

brief

review

given

with

gested

management

A

case

nancy

is with

umbilical

the

of

hernia

recent

literature

symptoms,

of abdominal

reported the

the

signs, of fetal

arm

requiring

an

abdominal incarcerated

is

and

sug-

pregnancy. pregto

an

operation.

REFERENCES

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84 1

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pregnancy

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into

hernia

75

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Drive California