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DELAYED BUT SUCCESSFUL TREATMENT OF RUPTURED UTERUS
1260 DELAYED BUT SUCCESSFUL TREATMENT OF RUPTURED UTERUS
flown home admission.
who had a ruptured uterus and a foetus in the abdomen for over sixty hours survived and was cured of all the resulting complications.
At her
SiR,-A
woman
A Mosotho woman of 38, living far in the mountains, went into labour about midday on Oct. 23, 1960. She was looked after by her mother. (She was para 6, the first being stillborn; the other five children were all delivered normally and were alive and well). A very strong labour ensued and 16 hours later ceased suddenly before the baby was delivered. She was carried to the Mountain Dispensary at Semongkong where the Mosotho dispenser treated her with phenobarbitone tablets while he tried to arrange for an aeroplane to collect her from the nearby airstrip. Bad weather prevented the plane from fetching her for 21/2 days. At last, after 1/2 hour’s flight she was admitted to hospital in Maseru at 4.30 P.M. on Oct. 26. She was in extremis: her pulse was 160 and blood-pressure 80/0 mm. Hg. She was obviously anaemic and dehydrated. There was an easily palpable superficial foetal head above the pubis. A diagnosis of ruptured uterus was made, she was given morphine (gr. 1/6) and atropine (gr. 1/100), intravenous plasma was set up, and she was taken to the theatre. Anaesthesia was induced with thiopentone and suxamethonium chloride and a cuffed endotracheal tube was passed, anxsthesia being maintained with nitrous oxide, oxygen, trichlorethylene, and gallamine
Flaxedil ’). A macerated male foetus weighing about 8 lb. was found in the peritoneal cavity, and there was a very low rupture of the anterior lower uterine segment which extended into the broad ligament on the left side. There was gross bruising of the bladder and considerable peritonitis. The uterine muscle was infected and friable. A subtotal hysterectomy and bilateral " salpingo-oopherectomy of the " smash-and-grab variety was performed. Two pints of blood were given postoperatively, and streptomycin (l.g.) and procaine penicillin (2 ml.) were given twice daily. The bladder was drained continuously for five days with an ordinary catheter instead of a Foley’s. The patient’s condition improved steadily and on the 6th postoperative day the hsemoglobin was 86% and doses of antibiotics were halved. Thereafter the wound became septic and broke down on the llth day, and secondary suture was performed by using vertical mattress sutures and double dolly dressings. The sutures were removed 14 days later. Penicillin and streptomycin were stopped and chloramphenicol (250 mg. q.d.s.) was given for 16 days. 3 weeks after operation a further pint of blood raised the haemoglobin to 90%. By this time a vesicovaginal fistula had developed and failed to close despite reinstitution of continuous bladder drainage. Convalescence was further complicated by obstetric palsies
(bilateral foot drop and gross wasting of leg muscles, worse on side), but these improved steadily over the weeks with massage and exercises and were finally cured. 8 weeks after operation she had an episode of subacute largegut obstruction, fortunately relieved by enemas. 6 weeks later the vaginal sloughs had separated. Examination under antsthesia showed that there were no vaginal strictures, but a midthe left
line vesicovaginal fistula was discovered just anterior to the cervix and admitting the tip of a finger easily. This was repaired two weeks later by freeing the bladder on the posterior edge of the fistula and bringing it up as a flap behind the anterior edge with interrupted mattress sutures of dermalon. The freshened edges of the vaginal mucosa were approximated with interrupted sutures of dermalon. On removal of the sutures a very small fistula remained which was situated in the midline and admitted a probe easily. A month later this fistula was repaired from side to side using the method described by Chassar Moir. This, unfortunately, sloughed and broke down leaving a slightly larger fistula which was repaired a month later using the original technique. This time the repair was successful and the patient was
to
her
family fully recovered,
7 months after
original operation a bilateral salpingo-oophorectomy performed because it was judged to be a quicker procedure than conserving the tubes and ovaries. The sole object of the operation was to save the patient’s life. It is our routine to drain the bladder after all badly obstructed labours for five days since we feel that the incidence of vesicovaginal fistula is thereby reduced. A Foley’s catheter is never used because the bulb presses on that part of the bladder most likely to slough. It is most unusual for patients who are malnourished, as this woman was, to survive a ruptured uterus of more was
than twelve hours’ duration. We attribute her recovery to: modern anxsthesia; immediate operation combined with resuscitation (in our experience it is a waste of time to wait for the patient’s condition to improve before operating as it so seldom does); the fact that there was no fierce haemorrhage when the uterus ruptured; and the fact that the infecting organisms were obviously sensitive to the antibiotics given (this is one of the few distinct advantages of being relatively far from civilisation and its antibiotics and resistant organisms). Our thanks are due to the Director of Health, Basutoland, for permission to publish this
case.
D. G. STANDING Maseru, Basutoland.
J. H. DALY BRISCOE.
TOLBUTAMIDE IN CIRRHOSIS OF THE LIVER SiR—1read with great interest the paper by Prof. Inder Singh and his colleagues.! It is surprising that tolbutamide should have been used in cirrhosis of the liver, for the following reasons:
(1) " Tolbutamide interferes with various enzyme systems in the liver. Tolbutamide should not be given to patients with liver damage."2 (2) Tolbutamide may prolong the action of barbiturates.2 Since tolbutamide by itself has no hypnotic actions of its own, it acts by interfering with the detoxification mechanism at the liver. This is analogous to the action of SKF 525A. (3) Tolbutamide apparently also interferes with the detoxification of alcohol. The enzyme systems concerned in the oxidation of alcohol are blocked in the same way as by T.E.T.D. Your contributors state that tolbutamide increases the glycogen content of the liver and consequently may protect the liver from various types of injury. If the aim was to increase the glycogen content of the liver only, why not achieve the same result by injections of insulin and glucose instead of using a known hepatotoxic drug ? Department of Pharmacology, Medical College, Calicut, India.
*** We showed Dr. Iyer’s letter reply follows.-ED. L.
K. SAMU IYER. to
Prof. Inder
Singh and
his
SiR,—Tolbutamide does not appear in the latest list of drugs that may cause liver damage.3 There is also considerable evidence that tolbutamide does not have any toxic effect even on the damaged liver. In fact, Laszlo et al. have treated acute hepatitis with the drug and reported rapid decrease in serum-bilirubin and quicker recoverytime. Before we started our work, we were aware of the interference in the detoxication of alcohol and barbiturates by tolbutamide. Occasional intolerance to alcohol was already described in the 1. Singh, I., Sehra, K. B., Bhargava, S. P. Lancet, 1961, i, 1144. 2. New and Non-official Drugs; p. 486. Philadelphia, 1958. 3. Beckman, H. Pharmacology; p. 312. London, 1961. 4. László, B., Bruckner, P., Görgey, E., Tóth, B. Orv. Hetil. 1959,
100, 1411.
flown home admission.
who had a ruptured uterus and a foetus in the abdomen for over sixty hours survived and was cured of all the resulting complications.
At her
SiR,-A
woman
A Mosotho woman of 38, living far in the mountains, went into labour about midday on Oct. 23, 1960. She was looked after by her mother. (She was para 6, the first being stillborn; the other five children were all delivered normally and were alive and well). A very strong labour ensued and 16 hours later ceased suddenly before the baby was delivered. She was carried to the Mountain Dispensary at Semongkong where the Mosotho dispenser treated her with phenobarbitone tablets while he tried to arrange for an aeroplane to collect her from the nearby airstrip. Bad weather prevented the plane from fetching her for 21/2 days. At last, after 1/2 hour’s flight she was admitted to hospital in Maseru at 4.30 P.M. on Oct. 26. She was in extremis: her pulse was 160 and blood-pressure 80/0 mm. Hg. She was obviously anaemic and dehydrated. There was an easily palpable superficial foetal head above the pubis. A diagnosis of ruptured uterus was made, she was given morphine (gr. 1/6) and atropine (gr. 1/100), intravenous plasma was set up, and she was taken to the theatre. Anaesthesia was induced with thiopentone and suxamethonium chloride and a cuffed endotracheal tube was passed, anxsthesia being maintained with nitrous oxide, oxygen, trichlorethylene, and gallamine
Flaxedil ’). A macerated male foetus weighing about 8 lb. was found in the peritoneal cavity, and there was a very low rupture of the anterior lower uterine segment which extended into the broad ligament on the left side. There was gross bruising of the bladder and considerable peritonitis. The uterine muscle was infected and friable. A subtotal hysterectomy and bilateral " salpingo-oopherectomy of the " smash-and-grab variety was performed. Two pints of blood were given postoperatively, and streptomycin (l.g.) and procaine penicillin (2 ml.) were given twice daily. The bladder was drained continuously for five days with an ordinary catheter instead of a Foley’s. The patient’s condition improved steadily and on the 6th postoperative day the hsemoglobin was 86% and doses of antibiotics were halved. Thereafter the wound became septic and broke down on the llth day, and secondary suture was performed by using vertical mattress sutures and double dolly dressings. The sutures were removed 14 days later. Penicillin and streptomycin were stopped and chloramphenicol (250 mg. q.d.s.) was given for 16 days. 3 weeks after operation a further pint of blood raised the haemoglobin to 90%. By this time a vesicovaginal fistula had developed and failed to close despite reinstitution of continuous bladder drainage. Convalescence was further complicated by obstetric palsies
(bilateral foot drop and gross wasting of leg muscles, worse on side), but these improved steadily over the weeks with massage and exercises and were finally cured. 8 weeks after operation she had an episode of subacute largegut obstruction, fortunately relieved by enemas. 6 weeks later the vaginal sloughs had separated. Examination under antsthesia showed that there were no vaginal strictures, but a midthe left
line vesicovaginal fistula was discovered just anterior to the cervix and admitting the tip of a finger easily. This was repaired two weeks later by freeing the bladder on the posterior edge of the fistula and bringing it up as a flap behind the anterior edge with interrupted mattress sutures of dermalon. The freshened edges of the vaginal mucosa were approximated with interrupted sutures of dermalon. On removal of the sutures a very small fistula remained which was situated in the midline and admitted a probe easily. A month later this fistula was repaired from side to side using the method described by Chassar Moir. This, unfortunately, sloughed and broke down leaving a slightly larger fistula which was repaired a month later using the original technique. This time the repair was successful and the patient was
to
her
family fully recovered,
7 months after
original operation a bilateral salpingo-oophorectomy performed because it was judged to be a quicker procedure than conserving the tubes and ovaries. The sole object of the operation was to save the patient’s life. It is our routine to drain the bladder after all badly obstructed labours for five days since we feel that the incidence of vesicovaginal fistula is thereby reduced. A Foley’s catheter is never used because the bulb presses on that part of the bladder most likely to slough. It is most unusual for patients who are malnourished, as this woman was, to survive a ruptured uterus of more was
than twelve hours’ duration. We attribute her recovery to: modern anxsthesia; immediate operation combined with resuscitation (in our experience it is a waste of time to wait for the patient’s condition to improve before operating as it so seldom does); the fact that there was no fierce haemorrhage when the uterus ruptured; and the fact that the infecting organisms were obviously sensitive to the antibiotics given (this is one of the few distinct advantages of being relatively far from civilisation and its antibiotics and resistant organisms). Our thanks are due to the Director of Health, Basutoland, for permission to publish this
case.
D. G. STANDING Maseru, Basutoland.
J. H. DALY BRISCOE.
TOLBUTAMIDE IN CIRRHOSIS OF THE LIVER SiR—1read with great interest the paper by Prof. Inder Singh and his colleagues.! It is surprising that tolbutamide should have been used in cirrhosis of the liver, for the following reasons:
(1) " Tolbutamide interferes with various enzyme systems in the liver. Tolbutamide should not be given to patients with liver damage."2 (2) Tolbutamide may prolong the action of barbiturates.2 Since tolbutamide by itself has no hypnotic actions of its own, it acts by interfering with the detoxification mechanism at the liver. This is analogous to the action of SKF 525A. (3) Tolbutamide apparently also interferes with the detoxification of alcohol. The enzyme systems concerned in the oxidation of alcohol are blocked in the same way as by T.E.T.D. Your contributors state that tolbutamide increases the glycogen content of the liver and consequently may protect the liver from various types of injury. If the aim was to increase the glycogen content of the liver only, why not achieve the same result by injections of insulin and glucose instead of using a known hepatotoxic drug ? Department of Pharmacology, Medical College, Calicut, India.
*** We showed Dr. Iyer’s letter reply follows.-ED. L.
K. SAMU IYER. to
Prof. Inder
Singh and
his
SiR,—Tolbutamide does not appear in the latest list of drugs that may cause liver damage.3 There is also considerable evidence that tolbutamide does not have any toxic effect even on the damaged liver. In fact, Laszlo et al. have treated acute hepatitis with the drug and reported rapid decrease in serum-bilirubin and quicker recoverytime. Before we started our work, we were aware of the interference in the detoxication of alcohol and barbiturates by tolbutamide. Occasional intolerance to alcohol was already described in the 1. Singh, I., Sehra, K. B., Bhargava, S. P. Lancet, 1961, i, 1144. 2. New and Non-official Drugs; p. 486. Philadelphia, 1958. 3. Beckman, H. Pharmacology; p. 312. London, 1961. 4. László, B., Bruckner, P., Görgey, E., Tóth, B. Orv. Hetil. 1959,
100, 1411.