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Advanced Abdominal Pregnancy
ADVANCED ABDOMINAL PREGNANCY LOUISE BRANSCOMB,
lVI.D., l:<'.A.C.S.,
BIRMINGHAM, ALA.
(From the Department c>f Gynecology an
pregnancy is so rare that only a few clinicians encounter an occasional case. For this reason it is interesting that within A a period of two months the three cases reported here should have been seen in a DVANCED abdominal
single hospital. In treating the cases, two practical question.<; arose to which answers were not easily found in the literature. These were ( 1) the length of time required for the placenta to become avascular when left in the abdomen after the death of the patient or removal of the fetus, and ( 2) the time necessary :for absorption of the retained placenta. In the individual case the time at which the placenta becomes avascular can be determined by a pregnancy test. Eisman and Ziegler had a case in which the child was living at operation and the placenta was left intact. Eight days later the Aschheim-Zondek test was negatiYe. MacGregor's patient had a negative test ten days after removal of the fetus. On the other hand, in the first case reported here, the Priedman was positive on the fifty-third postoperative day and becmne negative on the- fifty-eighth. A patient of Hart had a positive test one hundred days after fetal movements were last felt. Lull had a patient on whom the Friedmm1 was positive on the forty-fifth postoperative day. At laparotomy fifty-six days after the original operation, the placenta wa.necrotic. He suggests that if the patient is first seen after death of the fetus three to four weeks be allowed to elapse before operation, if her rondition warrants. This gives a reasonable time in which separation and necrosis of the placenta may proceed, and makes the possibility of safe removal of the placenta more Hkely. The patient should be watehed during the time for evidence of abdominal hemorrhage or infection. The second question •vhich arose was the length of time required for absorption when the placenta is left in the abdomen. \Vhen not removed the placenta may absorb, it may liquefy, or it may suppurate. Suppuration requires surgical drainage. However, drainage of the mass. as >vonld be expected, hastens its disappearance. When there is no suppuration, there is usually no pain nor discomfort, but resolution of the placental mass takes months or even years. In the second of our cases liquefaction without suppuration took place. Eight months after operation the mass was the size of a six months' uterine pregnancy. J\facGregor reports a similar case in which at the end of sixte€n months the sac was the size of an orange. A patient seen by l\fason had a residual mass two inches long after five months. Studdiford has seen a ease in which at the end of thirteen months a pelvic mass was still felt, while Jewett's patient had a small residuum two and one-half years after operation. In none of these patients was there any abdominal discomfort. CASE 1.-The patient was a Negro woman 28 years of age, who had had no previous pregnancy. Her last menstrual period was Nov. 25, 1945. On January 20 she developed lower abdominal pain. The pain was not knifelike, and she did not faint, but after two days of the pain s1Je developed moderate vaginal bleeding which persisted for eight days. There was no further pain nor bleeding. Fetal movements were felt about April 20.
871
Volume 54 Number 5
ADVANCED ABDOMINAL PREGNANCY
875
The patient was first seen on May 20. She had no complaint. The abdomen had the appearance of an eight months' pregnancy, but enlargement on the right was more prominent than on the left. Small parts could not be palpated. The fetal heart tones were heard in the left lower quadrant. On vaginal examination the cervix was soft. The fundus could not be outlined, and pressure on the abdominal mass from above did not cause movement of the cervix. On rectal examination a cystic mass could be felt extending into the cul-de-sac. Small parts were felt in this mass. When an extremity in the cul-de-sac was caught by the examining fingers it moved vigorously. X-ray showed a seven months' :fetus in transverse position. No placenta shadow could be seen. A diagnosis of abdominal pregnancy was made, and immediate operation advised. On opening the abdomen on May 23, a bluish glistening mass was found filling the lower abdomen and extending three fingerbreadths above the umbilicus. The mass was adherent to the small intestines above, and to the posterior surface of the uterus below. As there were no adhesions to the anterior surface of the sac, and as the surface here was glistening, this area was thought to be made up of membranes only, and a longitudual incision was made through it. The entire incision went directly through the underlying placenta which was about one-half inch in thickness. Due to the necessity to complete the operation as soon as possible because of bleeding, no further investigation of the relationship of the pelvic organs to the sac was made. After the operation was completed, it was realized that the fact that the sac had a complete peritoneal envelope meant that rupture of the original tubal pregnancy had taken place into the broad ligament on the left and that the fetus and fetal products were contained between the leaves of the ligament. At operation on opening the sac there was a gush of amniotic fluid, and a live seven months' female infant was delivered. The ehild died two hours later. Autopsy revealed no anomalies. Bleeding from the cut edges of the placenta was profuse but was controlled by ring forceps, which were carefully replaced by sutures. Manipulation, however, had started bleeding from tbe placenta deep in the sac. Two two-yard gauze packs were used to check the bleeding. The abdomen was closed, space being left only for the exit of the gauze drains. The patient left the table with a blood pressure of 80/0. She had received 500 c.c. of blood on the operating table, and was given an additional 1,000 c.c. during the next thirty-six hours. On the second postoperative day the drains were gently loosened, and about one foot of each removed. This procedure wa."! repeated daily until all of the pack had been removed by the seventh day. Blood was ·kept in readiness for immediate transfusion in the event of a postoperative hemorrhage, hut at no time was there any fresh bleeding. The patient, however, developed a rather free dark brmvn discharge from the wound. She left the hospital on the sixteenth day. At that time her hemoglobin was 65 per cent and she had no elevation of temperature. Three weeks after delivery a little milk appeared in the breasts. A week later she passed a large sheet of decidual tissue. Seven weeks after operation the patient developed a moderate grade fever and abdominal pain, and on examination showed a mass the size of a grapefruit near the umbilicus. She was readmitted to the hospital. Chemotherapy largely controlled the fever, but the pain persisted and the abdominal mass increased in size. A Friedman test on August 8 was positive. On August 13, fifty-eight days after removal of the infant, it became negative. The brown discharge from the abdominal wound had persisted and, in spite of iron and liver by mouth, an occasional transfusion was necessary to keep the patient's hemoglobin to a level of 60 per cent.
876
BHASi'ICOl\fB
c\m. ]. Obst. &.Gyner. "'ovember. 1947
On August 24 the nee.rotie placenta was removed. The opening in the sac had sealed over, and the petsistent diseharge was coming from the abdomen and not the sac•. On ineising· the sac about 30 c·.c·. of thic·k pu.-; ponred out. Five grams of sulfanilamide powder were sprinkled into the saC' and three Penrose drains inserted, whieh 'vere removed on tlw third day. On the sixth day the patient complained of 1·retal pain, her temperature was 100° F., and a cystic tender mass the size of a golf hall was felt in the eul-eu fom months aft<'r operation, the patient looked well 'tnd had no complaint. On pel vie examination, a slig·htly tender mass the size of a ping-pong ball eould he felt in the right fornix. No othe1· p<•lvie ahnormality was made out. CAt-lE 2.~The patient was a 36-year-old woman, gravida vii pata iii, who entered the ho:,;pital on ,June 27, 1946. Her last menstrual period \vas about August 20, ten months lwfore admission. On Oetober 2, when rising from her chair, she developed a sharp pain in the right lower quadrant and had to be carried to her hed. For the m•xt three days ~lw had a ~potting of hright red blood. There was no further vaginal hhwling until tlw da~-' hefore admission when there was again a small amount of bright reel hloofl. The patient was not well from the time of her first attack of pain until her admission to the hospital. Slw had fr<>qnent attacks of vomiting, faintness, and abdominal pain. She was set'n by several different doetors who thought that she was having threatened abortion or had a pelvic infection along with a uterine pregnam·y. The first Jetal mon•ments Wt'I'c fvlt in ()pc·ember. As soon as movements became vigorous (about Jamwr~T 10) the~T were accompanied by so much pain that the patient could not sleep. The movement was always on the right side of the abdomen. I<'etal movements wc·1·e last felt on J\lay 22. On June 26, the patient developecl and the c·ord was cut Rhort and tied. The abdomen was rlosed without drainage. The patient's postoperative course WHS uneventful. During the first eleven days there was an Plevation of temperature to from 100.1;:o to 99.4° F., after which there was no fmther fever.
Volume 54 Number 5
ADVANCED ABDOMINAL PREGNANCY
877
She was discharged on the nineteenth postoperative day. At that time there was a rounded mass in the abdomen that reached 3 em. above the umbilicus. The patient was seen at frequent intervals following this. She had no complaint, and normal menstruation was resumed. The mass gradually decreased in size, but seven months after operation it still extended one fingerbreadth above the umbilicus and dipped into the pelvis below. It was about 10 em. long and 6 em. across. The fundus was average size and could be felt anterior to and adherent to this mass. CASE 3.-The patient was a Negro woman 31 years of age, gravida i, para 0, whose last menstrual period was July 10, 1945. Five weeks later she developed a scant bloody discharge, had severe lower abdominal pain, and fainted. During the fourth month there was a return of this pain and the patient was admitted to the hospital on November 9. Her temperature was 100° P., pulse 88, white blood cells 5,800, and hemoglobin 57 per cent. The uterus extended three fingerbreadths below the umbilicus, and a tender mass was felt in the left fornix and extending into the cul-de-sac. A diagnosis of uterine pregnancy and acute salpingitis was made. With chemotherapy the fever subsided and after receiving 500 c.c. of blood the patient was discharged on November 19. Twice during the next six weeks she was readmitted for colicky pain, nausea and vomiting, abdominal distention, and obstipation. An x-ray of the abdomen showed multiple fluid levels in the intestines, and a diagnosis of intestinal obstruction was made. The condition responded promptly to the use of a Miller-Abbott tube, but after relief of the obstruction there was a tendency for recurrence of the attacks of abdominal pain. On one of these oocasions the patient again fainted. On April 10, nine months after the onset of the last menstrual period, the patient developed rhythmic pains and was admitted to the obstetric ward. The abdomen was enlarged to the size of a term pregnancy, and fetal heart tones were heard in the right lower quadrant. Small parts could not be outlined. The cervix was long and the os closed. Posterior to the cervix a firm mass about 6 em. in diameter could be felt. Anterior to the cervix two smaller nodules could be felt. A diagnosis of uterine pregnancy at term with uterine fibroids blocking the pelvic outlet was made. It was decided that delivery should be done by cesarean section. Pive hundred cubic centimeters of blood were given before taking the patient to the operating room. On opening the abdomen a large oval mass which was thought to be the pregnant uterus was found. This was opened, and a 2:t,2-pound living male child was extracted without difficulty. It was then seen that the mass was not the uterus but the sac of an abdominal pregnancy. The sac showed a rent in its posterior wall and its cavity contained several old organized blood clots. The placenta was adherent to the transverse colon, small intestines, and posterior abdominal wall. The fundus was the mass that had been felt in the cul-de-sac before operation, and it showed two fibroid nodules on its anterior wall. At operation the fetal sac had been opened through a part of the placental site, and bleeding here was free. No attempt was made to remove the placenta, but there was profuse bleeding from the depth of the sac. Three five-yard gauze rolls were pushed into the sac, and the edge of the sac anchored to the peritoneal edges. The abdomen was closed, allowing space only for the exit of the drains. The patient's condition was poor during the operation. She received stimulants and 1,250 c.c. of blood while in the operating room. On leaving the room her blood pressure was 75/30, pulse 120. She was treated for shock but did not respond, and di.ed four hours after operation. Permission for autopsy
878
BRANSCOMB
Am.]. Obst. & Gynec. November. 19~7
could not be obtained, but it was thought that due to the rent ih the posterior wall of the sac the pack was not effective and that the patient died of internal hemorrhage. The infant had no evidence of any defect, and three months after delivery is living and well. I wish to express my thanks to Dr. J. H. Williams for allowing me to present the second of these eases.
References 1. 2. 3. 4. 5. 6. 7.
Eisman, J. H., and Ziegler, C. E.: ,J. A. M. A. 104: ~175, Hl35. MacGregor, Arthur: AM. J. 0BST. & GYNEC. 34: 1030, 1937. Hart, D. Samuel: West. J. Surg. 51: 280, 1943. Lull, Clifford B.: AM. J. OBST. & GYNEC. 40: 195, 1940. Mason, Lyman W.: AM . •T. 0BST. & GYNEC. 39: 7f56, 1940. Studdiford, William C.: (Discussion) AM. J. OBST. & GYNEC. 40: 201, 1940. Jewett, William A.: (Discussion) AM. J. 0BST. & GYNEC. 40: 201, 1940.
lVI.D., l:<'.A.C.S.,
BIRMINGHAM, ALA.
(From the Department c>f Gynecology an
pregnancy is so rare that only a few clinicians encounter an occasional case. For this reason it is interesting that within A a period of two months the three cases reported here should have been seen in a DVANCED abdominal
single hospital. In treating the cases, two practical question.<; arose to which answers were not easily found in the literature. These were ( 1) the length of time required for the placenta to become avascular when left in the abdomen after the death of the patient or removal of the fetus, and ( 2) the time necessary :for absorption of the retained placenta. In the individual case the time at which the placenta becomes avascular can be determined by a pregnancy test. Eisman and Ziegler had a case in which the child was living at operation and the placenta was left intact. Eight days later the Aschheim-Zondek test was negatiYe. MacGregor's patient had a negative test ten days after removal of the fetus. On the other hand, in the first case reported here, the Priedman was positive on the fifty-third postoperative day and becmne negative on the- fifty-eighth. A patient of Hart had a positive test one hundred days after fetal movements were last felt. Lull had a patient on whom the Friedmm1 was positive on the forty-fifth postoperative day. At laparotomy fifty-six days after the original operation, the placenta wa.necrotic. He suggests that if the patient is first seen after death of the fetus three to four weeks be allowed to elapse before operation, if her rondition warrants. This gives a reasonable time in which separation and necrosis of the placenta may proceed, and makes the possibility of safe removal of the placenta more Hkely. The patient should be watehed during the time for evidence of abdominal hemorrhage or infection. The second question •vhich arose was the length of time required for absorption when the placenta is left in the abdomen. \Vhen not removed the placenta may absorb, it may liquefy, or it may suppurate. Suppuration requires surgical drainage. However, drainage of the mass. as >vonld be expected, hastens its disappearance. When there is no suppuration, there is usually no pain nor discomfort, but resolution of the placental mass takes months or even years. In the second of our cases liquefaction without suppuration took place. Eight months after operation the mass was the size of a six months' uterine pregnancy. J\facGregor reports a similar case in which at the end of sixte€n months the sac was the size of an orange. A patient seen by l\fason had a residual mass two inches long after five months. Studdiford has seen a ease in which at the end of thirteen months a pelvic mass was still felt, while Jewett's patient had a small residuum two and one-half years after operation. In none of these patients was there any abdominal discomfort. CASE 1.-The patient was a Negro woman 28 years of age, who had had no previous pregnancy. Her last menstrual period was Nov. 25, 1945. On January 20 she developed lower abdominal pain. The pain was not knifelike, and she did not faint, but after two days of the pain s1Je developed moderate vaginal bleeding which persisted for eight days. There was no further pain nor bleeding. Fetal movements were felt about April 20.
871
Volume 54 Number 5
ADVANCED ABDOMINAL PREGNANCY
875
The patient was first seen on May 20. She had no complaint. The abdomen had the appearance of an eight months' pregnancy, but enlargement on the right was more prominent than on the left. Small parts could not be palpated. The fetal heart tones were heard in the left lower quadrant. On vaginal examination the cervix was soft. The fundus could not be outlined, and pressure on the abdominal mass from above did not cause movement of the cervix. On rectal examination a cystic mass could be felt extending into the cul-de-sac. Small parts were felt in this mass. When an extremity in the cul-de-sac was caught by the examining fingers it moved vigorously. X-ray showed a seven months' :fetus in transverse position. No placenta shadow could be seen. A diagnosis of abdominal pregnancy was made, and immediate operation advised. On opening the abdomen on May 23, a bluish glistening mass was found filling the lower abdomen and extending three fingerbreadths above the umbilicus. The mass was adherent to the small intestines above, and to the posterior surface of the uterus below. As there were no adhesions to the anterior surface of the sac, and as the surface here was glistening, this area was thought to be made up of membranes only, and a longitudual incision was made through it. The entire incision went directly through the underlying placenta which was about one-half inch in thickness. Due to the necessity to complete the operation as soon as possible because of bleeding, no further investigation of the relationship of the pelvic organs to the sac was made. After the operation was completed, it was realized that the fact that the sac had a complete peritoneal envelope meant that rupture of the original tubal pregnancy had taken place into the broad ligament on the left and that the fetus and fetal products were contained between the leaves of the ligament. At operation on opening the sac there was a gush of amniotic fluid, and a live seven months' female infant was delivered. The ehild died two hours later. Autopsy revealed no anomalies. Bleeding from the cut edges of the placenta was profuse but was controlled by ring forceps, which were carefully replaced by sutures. Manipulation, however, had started bleeding from tbe placenta deep in the sac. Two two-yard gauze packs were used to check the bleeding. The abdomen was closed, space being left only for the exit of the gauze drains. The patient left the table with a blood pressure of 80/0. She had received 500 c.c. of blood on the operating table, and was given an additional 1,000 c.c. during the next thirty-six hours. On the second postoperative day the drains were gently loosened, and about one foot of each removed. This procedure wa."! repeated daily until all of the pack had been removed by the seventh day. Blood was ·kept in readiness for immediate transfusion in the event of a postoperative hemorrhage, hut at no time was there any fresh bleeding. The patient, however, developed a rather free dark brmvn discharge from the wound. She left the hospital on the sixteenth day. At that time her hemoglobin was 65 per cent and she had no elevation of temperature. Three weeks after delivery a little milk appeared in the breasts. A week later she passed a large sheet of decidual tissue. Seven weeks after operation the patient developed a moderate grade fever and abdominal pain, and on examination showed a mass the size of a grapefruit near the umbilicus. She was readmitted to the hospital. Chemotherapy largely controlled the fever, but the pain persisted and the abdominal mass increased in size. A Friedman test on August 8 was positive. On August 13, fifty-eight days after removal of the infant, it became negative. The brown discharge from the abdominal wound had persisted and, in spite of iron and liver by mouth, an occasional transfusion was necessary to keep the patient's hemoglobin to a level of 60 per cent.
876
BHASi'ICOl\fB
c\m. ]. Obst. &.Gyner. "'ovember. 1947
On August 24 the nee.rotie placenta was removed. The opening in the sac had sealed over, and the petsistent diseharge was coming from the abdomen and not the sac•. On ineising· the sac about 30 c·.c·. of thic·k pu.-; ponred out. Five grams of sulfanilamide powder were sprinkled into the saC' and three Penrose drains inserted, whieh 'vere removed on tlw third day. On the sixth day the patient complained of 1·retal pain, her temperature was 100° F., and a cystic tender mass the size of a golf hall was felt in the eul-
Volume 54 Number 5
ADVANCED ABDOMINAL PREGNANCY
877
She was discharged on the nineteenth postoperative day. At that time there was a rounded mass in the abdomen that reached 3 em. above the umbilicus. The patient was seen at frequent intervals following this. She had no complaint, and normal menstruation was resumed. The mass gradually decreased in size, but seven months after operation it still extended one fingerbreadth above the umbilicus and dipped into the pelvis below. It was about 10 em. long and 6 em. across. The fundus was average size and could be felt anterior to and adherent to this mass. CASE 3.-The patient was a Negro woman 31 years of age, gravida i, para 0, whose last menstrual period was July 10, 1945. Five weeks later she developed a scant bloody discharge, had severe lower abdominal pain, and fainted. During the fourth month there was a return of this pain and the patient was admitted to the hospital on November 9. Her temperature was 100° P., pulse 88, white blood cells 5,800, and hemoglobin 57 per cent. The uterus extended three fingerbreadths below the umbilicus, and a tender mass was felt in the left fornix and extending into the cul-de-sac. A diagnosis of uterine pregnancy and acute salpingitis was made. With chemotherapy the fever subsided and after receiving 500 c.c. of blood the patient was discharged on November 19. Twice during the next six weeks she was readmitted for colicky pain, nausea and vomiting, abdominal distention, and obstipation. An x-ray of the abdomen showed multiple fluid levels in the intestines, and a diagnosis of intestinal obstruction was made. The condition responded promptly to the use of a Miller-Abbott tube, but after relief of the obstruction there was a tendency for recurrence of the attacks of abdominal pain. On one of these oocasions the patient again fainted. On April 10, nine months after the onset of the last menstrual period, the patient developed rhythmic pains and was admitted to the obstetric ward. The abdomen was enlarged to the size of a term pregnancy, and fetal heart tones were heard in the right lower quadrant. Small parts could not be outlined. The cervix was long and the os closed. Posterior to the cervix a firm mass about 6 em. in diameter could be felt. Anterior to the cervix two smaller nodules could be felt. A diagnosis of uterine pregnancy at term with uterine fibroids blocking the pelvic outlet was made. It was decided that delivery should be done by cesarean section. Pive hundred cubic centimeters of blood were given before taking the patient to the operating room. On opening the abdomen a large oval mass which was thought to be the pregnant uterus was found. This was opened, and a 2:t,2-pound living male child was extracted without difficulty. It was then seen that the mass was not the uterus but the sac of an abdominal pregnancy. The sac showed a rent in its posterior wall and its cavity contained several old organized blood clots. The placenta was adherent to the transverse colon, small intestines, and posterior abdominal wall. The fundus was the mass that had been felt in the cul-de-sac before operation, and it showed two fibroid nodules on its anterior wall. At operation the fetal sac had been opened through a part of the placental site, and bleeding here was free. No attempt was made to remove the placenta, but there was profuse bleeding from the depth of the sac. Three five-yard gauze rolls were pushed into the sac, and the edge of the sac anchored to the peritoneal edges. The abdomen was closed, allowing space only for the exit of the drains. The patient's condition was poor during the operation. She received stimulants and 1,250 c.c. of blood while in the operating room. On leaving the room her blood pressure was 75/30, pulse 120. She was treated for shock but did not respond, and di.ed four hours after operation. Permission for autopsy
878
BRANSCOMB
Am.]. Obst. & Gynec. November. 19~7
could not be obtained, but it was thought that due to the rent ih the posterior wall of the sac the pack was not effective and that the patient died of internal hemorrhage. The infant had no evidence of any defect, and three months after delivery is living and well. I wish to express my thanks to Dr. J. H. Williams for allowing me to present the second of these eases.
References 1. 2. 3. 4. 5. 6. 7.
Eisman, J. H., and Ziegler, C. E.: ,J. A. M. A. 104: ~175, Hl35. MacGregor, Arthur: AM. J. 0BST. & GYNEC. 34: 1030, 1937. Hart, D. Samuel: West. J. Surg. 51: 280, 1943. Lull, Clifford B.: AM. J. OBST. & GYNEC. 40: 195, 1940. Mason, Lyman W.: AM . •T. 0BST. & GYNEC. 39: 7f56, 1940. Studdiford, William C.: (Discussion) AM. J. OBST. & GYNEC. 40: 201, 1940. Jewett, William A.: (Discussion) AM. J. 0BST. & GYNEC. 40: 201, 1940.