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Congenital hernia of umbilical cord with eventration and absence of A sac
CONCENITATJ HERNIA’OF EVENTRATION AND BY JOHN F. KRUMM, (Departnlent
of Gy?lecology
IJMBILICAL CORD WITH ABSENCE OF A SAC M.D., CHICAGO, ILL,
a,nd Obstetricrv,
No@western
University
Medical
School)
T
HE case I am about to report is one of complete eventration, with a small abdominal opening and with no evidence of any form of a sac; the bowels undoubtedly had been floating in the free amniotic fluid during intrauterine life. As occur8 in many of these cases, there were other associated embryonal defects and some of these probably explain the occurrence of the exaggerated conditions in this patient. The patient was a primipara, aged twenty-six years. Family history was negative except that grandmother of child on paternal side had a slight shortening of one upper extremity. The Wassermann test was negative. She had a spontaneous miscarriage of eight weeks’ duration in February, 1927.
Last menses occurred on July 4, 1927, calculated date of confinement April 11, 1928. Nausea and vomiting persisted until the end of the third month. Otherwise entire prenatal period was uneventful until onset of labor. Fetal heart tones were 144 at each visit, once every two weeks. Last visit was April 5, 1928, three days prior to onset of labor. On Sunday, April 8, patient was taken aut.omobile riding over rough streets with the idea of precipitating labor. Labor pains were first noted at 11 P.M. that same night, but they were so weak and irregular that she did not call the doctor until 8 A.M. the following morning, April 9. She was seen at 9 A.X. in the hospital and on examination the cervix was found to be dilated about one and one-half fingers and with very little effacement. Blood pressure was as usual, 110/72. The urine was negative. Pains were recurring every twenty-five to thirty minutes and of short duration. Fetal head was entered in pelvic inlet and position was left occipito-anterior. Fetal heart rate was 180 as compared to the former constant rate of 144. There was no vaginal show or other bleeding. Everything appeared normal except the fetal heart rate and in view of the foregoing history the possibility of a partial abruptio placenta with occult bleeding was considered. There were, however, no other confirmatory signs. The fetus without a doubt was in distress, but a rapid delivery could only be done by cesarean section. This was postponed and the fetal heart rate was taken every fifteen minutes without any‘change until complete dilatation occurred, and membranes were ruptured at about 5:30 P.Y. Immediately following this procedure the fetal heart rate rose to 19% as nearly as could be counted. Meconium now appeared at the vulva. An episiotomy and an immediate midforceps delivery were done, with a viable child born at G P.M. Examination of the child revealed the stomach and coils of small intestines and cecum, greatly distended, and these as well as the liver and omentum, protruded from an umbilical opening the size of a silver dollar and passed alongside the umbilical cord. The cord divided just before entering the abdominal cavity. There were no evidences of a covering for the viscera; the peritoneum ended at the umbilical opening, and only the cord itself was covered with a membrane. The stomach and coils of intestine were matted together in places and when separated a fibrinous material was seen. The viscera were not hyperemic but simulated ordinary bowel serosa. 442
On inserting a finger through the umt~ilieaI Opening Only a very small s1m1lOW cavity was found, hardly large enough to admit even one-half of the disttxdcd Any attempt to replace the r&era under these conditions UatUEdj WRS stomach. futile and 80 these were merely co~cre~l with moist warn1 gauze and the baby Was placed in an incubator where it remained alive for eightecu hours. T,:lter esamimltion rc~aled tllat tllrrc were fix dircrticzulac tllc size Of au average adult appudis, one on tllr Imstrrior ~111 Of tllc stoma?ll and the rest along Thcs transrcqx! ~Olou WIS screrecl in its midpoint by the the intestinal tract. TIIC rectum was found to he a mesentery and both ends were closed II~Y blindly. solid cord, the howel aho~e being normal I,ut, distended, and the anal canal below also appeared normal. Two toes Of tlw light foot ~vcrc webbccl, and the left foot was almost amputated at the Rnklr as a result Of thcl cord wiuding about at that point. I’robably tho embryologic arrest Of the re&nu and the blind endings of the transverse colon accounted for the distention of the bowels. Eren though the two cdgcs of the abdominal wall c’amc well together except at the umbilical opening, the howels were too greatly distended to permit Of their being drawn into the abdominal ca.vity, as in the n~rmnl case. Also tllis made it unnecessary for the abdominal rarity to dcy-elop at the, same pact> and to the same extent as the grO\vih of the cventrnted risecrn and tllus nn artificial reduction of the hernia was made impossible. It is also conceivahlc that the original sac which w:~s undoubtedly prrsrnt in early fetal life, ruptured, possibly under tension of the distended hoxels, and subscquently its edges retracted and atroljhied. Thcl etiology of the wrcrccl transwrse ~lon and Of the dix,rticulae is nOt as easily explained. Fortunately in this case conserl-ative obstetrics was resorted to, thus sparing the mother the added risk of a cesarcan section. From an embryologic, standpoint this rare anomaly is cspccially Of interest On account Of the small ahdominal opening associated with so marked an eventration. Also because Of the contrast of the shallow abdominal carity in comparisOn t0 the large viscera; and because of the abs~nct of a hernial sac. Clinically the case is interesting because of the absence Of abnormal symptoms or signs until the onset of labor; and because of the difficulties presented in determining a suitable means Of terminating labor. This patient gare birth to a nnrmal child in .J;rnuary, 1930. 4753
Davanzo: Ohstrt.
BROADWAY.
The Resistance of the r Ginec. 52: 133, 19::Il.
Hemoglobin
The author, employing the Kruger mctbod, crease of hsmoglohinic resistance ohser~d in man.
in
the
affirms animals
Gynecological
Field.
that the posthemorrhagic is not a constant finding SYDSEY JT~LIT~S
S. RcaocHr~r. E.
~~~~~~~~~~
Ann.
inin
of Gy?lecology
IJMBILICAL CORD WITH ABSENCE OF A SAC M.D., CHICAGO, ILL,
a,nd Obstetricrv,
No@western
University
Medical
School)
T
HE case I am about to report is one of complete eventration, with a small abdominal opening and with no evidence of any form of a sac; the bowels undoubtedly had been floating in the free amniotic fluid during intrauterine life. As occur8 in many of these cases, there were other associated embryonal defects and some of these probably explain the occurrence of the exaggerated conditions in this patient. The patient was a primipara, aged twenty-six years. Family history was negative except that grandmother of child on paternal side had a slight shortening of one upper extremity. The Wassermann test was negative. She had a spontaneous miscarriage of eight weeks’ duration in February, 1927.
Last menses occurred on July 4, 1927, calculated date of confinement April 11, 1928. Nausea and vomiting persisted until the end of the third month. Otherwise entire prenatal period was uneventful until onset of labor. Fetal heart tones were 144 at each visit, once every two weeks. Last visit was April 5, 1928, three days prior to onset of labor. On Sunday, April 8, patient was taken aut.omobile riding over rough streets with the idea of precipitating labor. Labor pains were first noted at 11 P.M. that same night, but they were so weak and irregular that she did not call the doctor until 8 A.M. the following morning, April 9. She was seen at 9 A.X. in the hospital and on examination the cervix was found to be dilated about one and one-half fingers and with very little effacement. Blood pressure was as usual, 110/72. The urine was negative. Pains were recurring every twenty-five to thirty minutes and of short duration. Fetal head was entered in pelvic inlet and position was left occipito-anterior. Fetal heart rate was 180 as compared to the former constant rate of 144. There was no vaginal show or other bleeding. Everything appeared normal except the fetal heart rate and in view of the foregoing history the possibility of a partial abruptio placenta with occult bleeding was considered. There were, however, no other confirmatory signs. The fetus without a doubt was in distress, but a rapid delivery could only be done by cesarean section. This was postponed and the fetal heart rate was taken every fifteen minutes without any‘change until complete dilatation occurred, and membranes were ruptured at about 5:30 P.Y. Immediately following this procedure the fetal heart rate rose to 19% as nearly as could be counted. Meconium now appeared at the vulva. An episiotomy and an immediate midforceps delivery were done, with a viable child born at G P.M. Examination of the child revealed the stomach and coils of small intestines and cecum, greatly distended, and these as well as the liver and omentum, protruded from an umbilical opening the size of a silver dollar and passed alongside the umbilical cord. The cord divided just before entering the abdominal cavity. There were no evidences of a covering for the viscera; the peritoneum ended at the umbilical opening, and only the cord itself was covered with a membrane. The stomach and coils of intestine were matted together in places and when separated a fibrinous material was seen. The viscera were not hyperemic but simulated ordinary bowel serosa. 442
On inserting a finger through the umt~ilieaI Opening Only a very small s1m1lOW cavity was found, hardly large enough to admit even one-half of the disttxdcd Any attempt to replace the r&era under these conditions UatUEdj WRS stomach. futile and 80 these were merely co~cre~l with moist warn1 gauze and the baby Was placed in an incubator where it remained alive for eightecu hours. T,:lter esamimltion rc~aled tllat tllrrc were fix dircrticzulac tllc size Of au average adult appudis, one on tllr Imstrrior ~111 Of tllc stoma?ll and the rest along Thcs transrcqx! ~Olou WIS screrecl in its midpoint by the the intestinal tract. TIIC rectum was found to he a mesentery and both ends were closed II~Y blindly. solid cord, the howel aho~e being normal I,ut, distended, and the anal canal below also appeared normal. Two toes Of tlw light foot ~vcrc webbccl, and the left foot was almost amputated at the Rnklr as a result Of thcl cord wiuding about at that point. I’robably tho embryologic arrest Of the re&nu and the blind endings of the transverse colon accounted for the distention of the bowels. Eren though the two cdgcs of the abdominal wall c’amc well together except at the umbilical opening, the howels were too greatly distended to permit Of their being drawn into the abdominal ca.vity, as in the n~rmnl case. Also tllis made it unnecessary for the abdominal rarity to dcy-elop at the, same pact> and to the same extent as the grO\vih of the cventrnted risecrn and tllus nn artificial reduction of the hernia was made impossible. It is also conceivahlc that the original sac which w:~s undoubtedly prrsrnt in early fetal life, ruptured, possibly under tension of the distended hoxels, and subscquently its edges retracted and atroljhied. Thcl etiology of the wrcrccl transwrse ~lon and Of the dix,rticulae is nOt as easily explained. Fortunately in this case conserl-ative obstetrics was resorted to, thus sparing the mother the added risk of a cesarcan section. From an embryologic, standpoint this rare anomaly is cspccially Of interest On account Of the small ahdominal opening associated with so marked an eventration. Also because Of the contrast of the shallow abdominal carity in comparisOn t0 the large viscera; and because of the abs~nct of a hernial sac. Clinically the case is interesting because of the absence Of abnormal symptoms or signs until the onset of labor; and because of the difficulties presented in determining a suitable means Of terminating labor. This patient gare birth to a nnrmal child in .J;rnuary, 1930. 4753
Davanzo: Ohstrt.
BROADWAY.
The Resistance of the r Ginec. 52: 133, 19::Il.
Hemoglobin
The author, employing the Kruger mctbod, crease of hsmoglohinic resistance ohser~d in man.
in
the
affirms animals
Gynecological
Field.
that the posthemorrhagic is not a constant finding SYDSEY JT~LIT~S
S. RcaocHr~r. E.
~~~~~~~~~~
Ann.
inin