- Email: [email protected]
Combined tubal and intrauterine pregnancy
COMBINED
TUBAL
AND
INTRAUTERINE
PREGNANCY”
Report of a Case ‘I’IIOMAS
(From
the Department
of
Obstetrics
and Gynecology,
King’s
G. BELL, M.D., STAUNTON. Daughters
\'A.
Hospitd)
T
HE simultaneous presence of intrauterine and extrauterine prcgnancics ill the same patient is nearly always described in the literature as a rare CCIIIdition. In 1952 Zarou and Syl found 415 published cases of this condition. Two reviews in 1956 by Viviano” and by Vasicka and Grable” brought this total to 444. There are 1 additional cases not. included in these latter reviews and reported since their publication.%-’ Thescb.added to the cast prcsenkd herewith, bring the total of reported casesto 449. According to the estimate of De\-oc and Pratt,Y hetcrotopic pregnancy might be expected to occur in one out of 30,000 pregnancies. If this estimate is COYrcct, about 130 such cases should occur annually in the United States alone. Even if this estimate is high, it. is evident that the actual number of cases far exceeds the reported casesand that the clondition is not, so very rare. The outcome of the intrauterine pregnancy in the following case has prompted a limited search of the literature for similar caseswith similar results without notable success. A rather high incidence of stillbirths and neonatal deaths in the case of the intrauterine twins is noted in some of the more recent reviews.‘. :i. !I The estensive researches of Ingall+’ and his associates have shown that most congenital anomalies originate as fetal manifestations of critical stress in pregnancy. They have produced specific anomalies in the central nervous systems and skeletons of mice I);\- crcatin g hypoxic stress at various stages of pregnancy. They concluded that a large class of congenital defects is preventable. They call for an attack on the problem in the hnma~l b>- tllch use on a. combined front of the threefold forces of laboratory, cli!lical. am1 epidemiological methodologies. Although no positive conclusions can be drawn from the following case, it does provide clinical evidence which may, when combined with cvidencc from other cases, bc nsrl’nl in this program. 11:tll had two previous uncomplieate~l pregThe patient, a 32-year-old white woman, nauaies with term deliveries of normal infants in 1948 and 1949. Her last normal menstrual Following this, she had no bleeding and no other diffiperiod had begun Nov. 30, 1951. culties except mild cramping abdominal pain until thr clay of admission, Feb. lS, 1952. On this date, she noted the sudden onset of so~ero pain in tltc loner abdomen. This grew physician who found her in steadily worst and after 4 hours she was seen b?; her family shock and brought her immediately to our hospit:lI. The skin was IJ:L~~. 1.001, am1 Upon arrival the patient was in ob~icmsly sev~rc (list rtfss. tlw bl~~~l pressure ;n/X. The hrnrt wits normal moist. The pulse was rapid and threally,
*Presented
Obstetricians
and
at the Nineteenth Annual Charleston, Gynecologists,
Meetins of the South Atlantic S. C., Feb. 6 to 9, 1957. 1270
dissociation
of
Volume 74 ANumher 6
COMBINED
TUBAL
AND
INTRAUTERINE
csccpt for tachycardia, the lungs were clear. present except in the abdomen and pelvis where made examination without anesthesia uselcsr. The serologic test for syphilis was negative.
1271
PREGNANCY
No other significant physical findings were the extreme degree of tenderness and rigidity The hemoglobin was 8.4 Gm. per 100 c.e.
‘The patient was prepared immediately for operation and given intravenous fluids and blood with fairly rapid improvement in the blootl pressure. Under general anesthesia, she was examined briefly and found to have a doughy mass filling the right side of the pelvis and cul-de-sac. The uterus was noted to be soft and symmetrically enlarged to a size comWithout further delay a laparotomy mensurate with a pregnancy of 8 to 10 weeks’ duration. was done. At least 1,000 C.C. of fresh and clotted blood was found in the abdomen and pelvis. The right tube was found to have a ruptured fusiform enlargement 4 cm. in diameter in its ampullar portion. The enlargement of the uterus was confirmed on direct examination. During and immediately following the operation a total Right salpingectomy was done. of 2,000 C.C. of blood was given. There was a slight amount of dark vaginal bleeding during the first two postoperative She had a febrile course during the first 3 days and days. She was not given hormones. was given penicillin. Otherwise her postoperative convalescence was uneventful. The urinary output Teas good. She was discharged on the ninth postoperative day. The
pathologist reported both a small fetus ant1 placenta in the excised tube. to have uterine enlargement consistent with a On March 31, 1952, she was fouml pregnancy of 16 weeks. She hat1 11x(1 no bleeding nor other difficulties since leaving the hospital. She was -follorvt(l through an aplarent.ly normal pregnancy until the thirtietlr week. On July 7, 1952,
lwstl)artum
Autopsy I have an<1 rwulting
~~n~~lw.w~~vt
of the infant followc~d this in spnnt~aneous
showed
am1 after 12 hours had a breech delivery of The tliagnosis of hydrocephalus was made After drainage of a large amount of intrawas
dend.
\\a?~ ullc:onll~lic~:~tp~l. no auomalics
other
patient through two deliveries of uorrual
tllan
the hydrocephalus
more pregnancies, infants at term.
and
entirely
clubfeet.
uncomplicated
Summary A case of hetepotopic pregnancy is reported in which the intrauterine fetus reached viability, but was hydrocephalic and died intra partum. It is felt that this is a stage-specific acquired anomaly and may reasonably be attributed to anoxic stress in the mother at, about the sixty-fifth day of pwgnancy.
References C. S., and Sy, A.: AK J. OBST. & GYNEC. 64: 1338, 1. Zarou, J. G.: AK J. OBST. & GYNEC. 72: 191, 195ti. 2. Viviano, Vasicka, A. I., and Grable, E. E.: Obst. & Gynee. Surv. 11: :_. Lawson, J. G., and Chouler, F. J.: J. Obst. & Gynaec. Brit. M. J. Australia 42: 1:536, 1955. Jacks, L. M.: ii: Selmeci, Orvosi hetil. (Budapest) 96: E., and Lakatos, G.: A., and Ferrera, C.: An. brasil. ginec. 39: 327, 7. de Moraes, 8. Devoe, R. W., and Pratt, J. H.: AM. J. OBST. & GYNEC. 56: 9. Reeves, C. P., and Savarese, M. F. R.: Obst. Bt Gynec. 4: 10. Ingalls, T. H.: J. A. M. A. 161: 1047, 3956.
1952.
603, 1956. Emp. 62: 951, 55, 1955. 1955. 1119,
492.
1948.
1951.
3955.
TUBAL
AND
INTRAUTERINE
PREGNANCY”
Report of a Case ‘I’IIOMAS
(From
the Department
of
Obstetrics
and Gynecology,
King’s
G. BELL, M.D., STAUNTON. Daughters
\'A.
Hospitd)
T
HE simultaneous presence of intrauterine and extrauterine prcgnancics ill the same patient is nearly always described in the literature as a rare CCIIIdition. In 1952 Zarou and Syl found 415 published cases of this condition. Two reviews in 1956 by Viviano” and by Vasicka and Grable” brought this total to 444. There are 1 additional cases not. included in these latter reviews and reported since their publication.%-’ Thescb.added to the cast prcsenkd herewith, bring the total of reported casesto 449. According to the estimate of De\-oc and Pratt,Y hetcrotopic pregnancy might be expected to occur in one out of 30,000 pregnancies. If this estimate is COYrcct, about 130 such cases should occur annually in the United States alone. Even if this estimate is high, it. is evident that the actual number of cases far exceeds the reported casesand that the clondition is not, so very rare. The outcome of the intrauterine pregnancy in the following case has prompted a limited search of the literature for similar caseswith similar results without notable success. A rather high incidence of stillbirths and neonatal deaths in the case of the intrauterine twins is noted in some of the more recent reviews.‘. :i. !I The estensive researches of Ingall+’ and his associates have shown that most congenital anomalies originate as fetal manifestations of critical stress in pregnancy. They have produced specific anomalies in the central nervous systems and skeletons of mice I);\- crcatin g hypoxic stress at various stages of pregnancy. They concluded that a large class of congenital defects is preventable. They call for an attack on the problem in the hnma~l b>- tllch use on a. combined front of the threefold forces of laboratory, cli!lical. am1 epidemiological methodologies. Although no positive conclusions can be drawn from the following case, it does provide clinical evidence which may, when combined with cvidencc from other cases, bc nsrl’nl in this program. 11:tll had two previous uncomplieate~l pregThe patient, a 32-year-old white woman, nauaies with term deliveries of normal infants in 1948 and 1949. Her last normal menstrual Following this, she had no bleeding and no other diffiperiod had begun Nov. 30, 1951. culties except mild cramping abdominal pain until thr clay of admission, Feb. lS, 1952. On this date, she noted the sudden onset of so~ero pain in tltc loner abdomen. This grew physician who found her in steadily worst and after 4 hours she was seen b?; her family shock and brought her immediately to our hospit:lI. The skin was IJ:L~~. 1.001, am1 Upon arrival the patient was in ob~icmsly sev~rc (list rtfss. tlw bl~~~l pressure ;n/X. The hrnrt wits normal moist. The pulse was rapid and threally,
*Presented
Obstetricians
and
at the Nineteenth Annual Charleston, Gynecologists,
Meetins of the South Atlantic S. C., Feb. 6 to 9, 1957. 1270
dissociation
of
Volume 74 ANumher 6
COMBINED
TUBAL
AND
INTRAUTERINE
csccpt for tachycardia, the lungs were clear. present except in the abdomen and pelvis where made examination without anesthesia uselcsr. The serologic test for syphilis was negative.
1271
PREGNANCY
No other significant physical findings were the extreme degree of tenderness and rigidity The hemoglobin was 8.4 Gm. per 100 c.e.
‘The patient was prepared immediately for operation and given intravenous fluids and blood with fairly rapid improvement in the blootl pressure. Under general anesthesia, she was examined briefly and found to have a doughy mass filling the right side of the pelvis and cul-de-sac. The uterus was noted to be soft and symmetrically enlarged to a size comWithout further delay a laparotomy mensurate with a pregnancy of 8 to 10 weeks’ duration. was done. At least 1,000 C.C. of fresh and clotted blood was found in the abdomen and pelvis. The right tube was found to have a ruptured fusiform enlargement 4 cm. in diameter in its ampullar portion. The enlargement of the uterus was confirmed on direct examination. During and immediately following the operation a total Right salpingectomy was done. of 2,000 C.C. of blood was given. There was a slight amount of dark vaginal bleeding during the first two postoperative She had a febrile course during the first 3 days and days. She was not given hormones. was given penicillin. Otherwise her postoperative convalescence was uneventful. The urinary output Teas good. She was discharged on the ninth postoperative day. The
pathologist reported both a small fetus ant1 placenta in the excised tube. to have uterine enlargement consistent with a On March 31, 1952, she was fouml pregnancy of 16 weeks. She hat1 11x(1 no bleeding nor other difficulties since leaving the hospital. She was -follorvt(l through an aplarent.ly normal pregnancy until the thirtietlr week. On July 7, 1952,
lwstl)artum
Autopsy I have an<1 rwulting
~~n~~lw.w~~vt
of the infant followc~d this in spnnt~aneous
showed
am1 after 12 hours had a breech delivery of The tliagnosis of hydrocephalus was made After drainage of a large amount of intrawas
dend.
\\a?~ ullc:onll~lic~:~tp~l. no auomalics
other
patient through two deliveries of uorrual
tllan
the hydrocephalus
more pregnancies, infants at term.
and
entirely
clubfeet.
uncomplicated
Summary A case of hetepotopic pregnancy is reported in which the intrauterine fetus reached viability, but was hydrocephalic and died intra partum. It is felt that this is a stage-specific acquired anomaly and may reasonably be attributed to anoxic stress in the mother at, about the sixty-fifth day of pwgnancy.
References C. S., and Sy, A.: AK J. OBST. & GYNEC. 64: 1338, 1. Zarou, J. G.: AK J. OBST. & GYNEC. 72: 191, 195ti. 2. Viviano, Vasicka, A. I., and Grable, E. E.: Obst. & Gynee. Surv. 11: :_. Lawson, J. G., and Chouler, F. J.: J. Obst. & Gynaec. Brit. M. J. Australia 42: 1:536, 1955. Jacks, L. M.: ii: Selmeci, Orvosi hetil. (Budapest) 96: E., and Lakatos, G.: A., and Ferrera, C.: An. brasil. ginec. 39: 327, 7. de Moraes, 8. Devoe, R. W., and Pratt, J. H.: AM. J. OBST. & GYNEC. 56: 9. Reeves, C. P., and Savarese, M. F. R.: Obst. Bt Gynec. 4: 10. Ingalls, T. H.: J. A. M. A. 161: 1047, 3956.
1952.
603, 1956. Emp. 62: 951, 55, 1955. 1955. 1119,
492.
1948.
1951.
3955.