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Dystocia due to Dilatation of the Fetal Urinary Bladder
DYSTOCIA DUE TO DILATATION OF THE FETAL URINARY BLADDER JoHN EDWARD SAVAGE, M.D., BALTIMORE, MD.
(From the Departments of Obstetrics al/l,d Pathology of the University of Maryland, School of Medicilne)
E G., twenty-two years old, colored, para vii.
Typhoid fever, uncomplicated, at . six years of age. No history of syphilis, tuberculosis, or other diseases. First pregnan.cy terminated in a full-term stillborn child, cause unknown. During the 5 succeeding pregnancies she was delivered by our clinic as an unregistered case. Each time her Kolmer reaction was negative and the pregnancies terminated spon· taneously at twenty weeks, twenty-four weeks, twenty weeks, twenty-three weeks, and twenty-two weeks, respectively. The causes for these abortions are unknown. All of the fetuses were male, and all the puerperiums were normal. Physical examinations were negative except during her fifth puerperium when there was a slight diffuse thyroid enlargement. Last menstrual period Sept. 14, 1933. Pregnancy uneventful. The Kolmer re· action was again negative. Without warning or pain the patient bled a small amount with dark clots on the eighteenth of February, 19341 and in an hour labor pains started. Labor appeared to be progressing normally and at 12:45 A.M., Feb. 19, 1934, the head was delivered. There was no further progress and the pains became weak and irregular. Bleeding had ceased with the descent of the head and did not recur after its delivery. All efforts to deliver the remainder of the fetus by traction were unsuccessful. The patient was then examined vaginally and a large, eystic, tense fetal abdomen was discovered, One finger was easily forced into the fetal umbilicus, releasing a considerable amount of clear fluid under pressure. The remainder of the delivery was then easily accomplished without further delay at 1:30 A.M. on the same date, the patient being delivered of a twenty· eight-week dead male fetus measuring 35 em. in length and weighing (1,132 gm.) 2 pounds 8 ounces. Placenta, membranes, and cord appeared normal. Because of the unusual history of this case a Kahn test was performed on the blood of the patient's husband, the result being strongly positive. THE FE'I'US
GrO&S.-The fetus (Fig. 1), male, measured 35 em. in length. The head was cyanotic and separated from the vertebral column, though not from the body. The costal margins and xiphoid prQcess we:re on the same plane, and the thorax was markedly eompressed. The abdominal wall was cyanotic and quite redundant and wrinkled, having been punctured at the umbilicus and the ill8ertion of the umbilical cord destroyed. The genitalia appeared normal but the testes had not descended into the scrotum. The only other gross anomaly noted was bilateral talipes equino· varus. The anus was perforate. A purse-string suture was placed about the aperture in the abdominal wall. The large bladder was filled with formalin, 1,000 c.e. being necessary to fill the cavity without forcing the fluid under pressure. The entire fetus was fixed thus and frozen when a median saggital section was made (Fig. 2).
216
SAVAGE :
277
DYSTOCIA
No evidence was seen of intracranial injury, and no gross abnormalities were noted in the heart, lungs, or trachea. The abdomen had been perforated at the umbilicus and no evidence of a mem branous area in this region as described by Spicer and 8chwyzer in their cases could be found. The most striking· feature was the urinary bladder which had been so distended that it compressed all the abdominal viscera and caused deformity of the thorax (Fig. 2). The bladder was loosely attached to the abdominal wall. The peritoneum showed no signs of inflammation, and there was no ascites. The stomach, intestines, liver, gallbladder, pancreas, and spleen appeared normal grossly. There was no communication between tl•e intestinal tract and the bladder. The bladder was greatly dilated, in the midline, and ~~onsisted of a single c:n·ity spherical in shape with uniform ou tline. The wall Yaried in thickness from 1.48
Fig. 1.
Fig.!!.
rom. to 0.4 em. at the urethral orifice. The interior of the bladder was smooth and fairly even and measured 16 by 12 by 10 em. The ureteral orifices were 8 em. apart, and the right 4.5 em., and the left 5 em. from the urethral orifice. Beginning at the vesical orifice a probe passed easily through the urethra until a point 0.3 em. from the external urinary meatus was approached where it stopped. Proximal to this obstruction the urethra was markedly dilated measuring 0.4 em. in diameter. (Black thread in Fig. 2 is in the urethra). At the point of obstruc· tion there was a marked narr~wing of the lumen of the ure1;hra to 0.19 mm. measured in serial sections of the spongy urethra. No complete obstruction could be demonstrated, and no other abnormality of the urethra was noticed. The ureters were dilated, the right lllld left measuring 1.0 em. lllld 1.7 em. in diameter, respectively, at their widest points. They were tortuous but no obstruction was demonstrable in either. Fig. 3 shows the left kidney, adrenal, ureter, testicle, and the left half of the bladder.
278
AMERlCAK JOURNAIJ OF OBSTETRICS AND GYN.ECOLOf;Y
The kidneys were lobulated and showed no cysts. 'rhe pyramids were somewhat flattened and the pelves dilated, but the kidn ey substance did not appear to be affected. The rigM kidne,Y measured :).5 by ::! hy 1 em .. and its pelvis :I .5 by 0. i5 em.; while the measurements of the left kidnPy and its pelvis were :{ by 2 hy 1 em. and 1.6 by 0.9 em., rt>~pec tiY el y. The arlrenal gland~ appeared normal. The left and right kidneys, adrenals, and testes ex hibited normal histology. The bladder wall was 1.48 mm. in thickness aud appearetl normal histologically although there was evidence of hypertrophy in the muscular wall. Fat stain was negati\'e for intracellular as wrll a~ intercPl:ular fat. Sectiom of the liver Rhowed normal architecture; and in those stained by Levaditi 's method no Spirocheta pallida were found. Rugae in the left ureter had heen smoothed out and evidences of edema and muscular hypertrophy were pre~e ut. The ureteml wall was 0.2G mm. in thickness f1·om its mucous memhrane including the tunica adventitia. The right ureter exhibited the same pic.ture tu a les;;H degree. 'l'he rugae were slightly flat· tened and the lumen was large. The wall measured 0.18 mm. in thickness. Serial sections of th e distal half of the peni~ •1Pmonstratrd a murked steno~is of the
F'ig. 3.
spongy urethra at its distal extremity. At its narrowest point the lumen measured 0.19 mm . in diametPr . No actual obstruetion was found. The fluid was pale yellow in eolor and water-dear in transparency. Its reaction was alkaline to litmus and acid to phenolphthalein; and its hydrogen ion concentration by the colorimetric method was i .4. The specific gravity was 1.0075. By Marshall's urease method urea was found to be present to the extent of 0.36 per cent; while chlorides as sodium chlOI'idc were found to be 0.17 per cent by the Volhard-Arnold method. Albumin wa~ present to the extent of less than 0.003 per cent. There was no odor. Aretone, diaeetir- arid, hlood, and bile were absent. Microscopic examination of the centrifug·ed specimen showed two types of cells: 1. Epithelial cells of the squamous type were found in small numbers only, but were typical in size, shape, and grouping·. Dispersed throughout their protoplasm, but not in the nucleus, refractile droplets were seen which va1·ied in size the largest of which were about one micron in diameter. B,v suitable staining methods these droplets were seen to be lipoid in character. 2. A large number of cells of a second t,vpe were seen. They were larger than the polymorphonudear· leuco<',vte and showetl predominantly a large, single, round or horseshoe nucleus. In th!'st~ cells also the lipoid droplets were present but the
GORDON:
RPPTURED PREGNANCY IX CT.Ol-'1<:[) H1'Jlll\1E:..(TAHT HOHJ\
~~/!)
indivir!ual droplets were larger. These <'.l'lls stainP
In view of the absence of both sug·ar anr! larger quantitit>s of protrin it \Va~ felt that the possibility of the fluid's lJPing a tran~wlat<> wa~ ruler! out. Walther reports the findinf_;- of Ppitht>lial r•t>llH and fat droplPts in th!• tluid in his case hut records no intrrwellular lipoid !lropl<'t~. I wish to express my sincere appreciation to Drs . .J. M. H. Rowland and L. H. Douglass of the Department of Obst<'tri<'s: Drs. H. R. SpenC'er an
RUPTURED PREGNANCY IN THE CLOSED RUDil\TEN'J'AH.Y HORN OF A BICORNATE liTERFS ExTERNAL .MIGRATION oF THE SPERMATAZOON; URINARY SuPPREsswx F'OLLOWING TRANSJ'o'USION CHARLES
A.
GORDON,
l\I.D., F.A.C.S.,
BROOKLYN,
X. Y.
THIS ease of pregnancy in the closed aceessory or rudimentary horn of a. bicornate uterus is reported because of its rarity, and the nature of tlw transfuswn death, and to record a definite instance of t>xternnl o1· peritoneal migration of the sperma~ tazoon. M. S., German, aged twenty-eight, married eleven ntonth:l, was admitted to f:.:t. Catherine's Hospital on March 18, 1933, romplaining of ahrlominal pain. Her last menstrual period occurred on Oct. 12, 1932, with a preYiously rPgular 28/4 menstrual eycle without pain or diseomfort at :my time. She had sought no prenatal care in this, lH•r first, pregnarwy, and had b]t bettl'r the next day but stayer! in bed. The next day, however, for(V·Pigltt hours aftn the first pain, she felt terrific pain in the abdomen and fainted, falling so heavily against the bath~ room door, that she sustained a wry severe t'Ontusion of the <"he!'k and chin, where a wide area of E>cehymosis and a. hematoma were prt'Rtmt. She was a well-developed young woman, very pal(', with lips, eonjunctival' and mucous membranes almost white, dry tongue, pulse 120, small and of poor quality. Her skin was cold. Heart sounds were of poor nmseular quality. Blood pressure was 120/65; temperature, 99.3; respiration, 34; H. B.C., 1,9i)0,00ll; W.B.C., 14,7fHJ; polymorphonuclears, 87; Hg, 36 per eent. Urim• was negativP. The abdomen was generally rigid, with marked peritoneal rebound pain, shifting dullness in the ftanks, and a firm, SOI!lewhat tender mass thought to be utPrus, hut all to the left of the median line, E>xt<•nding J em. above the umbili('US. Fetal h<'art l'Ould not be heard. The ct>rvix was soft, continuous with thP maRs felt abdominall~·, and there was no history or evidence of vaginal bkPding. A diagnosis of ruptured cornual pregnancy was made, and laparotomy undPr procaine infiltration and gas oxygen anesthesia presented no diffi<·ulties. The time of operation waR twenty~one minutes. Through a mi
(From the Departments of Obstetrics al/l,d Pathology of the University of Maryland, School of Medicilne)
E G., twenty-two years old, colored, para vii.
Typhoid fever, uncomplicated, at . six years of age. No history of syphilis, tuberculosis, or other diseases. First pregnan.cy terminated in a full-term stillborn child, cause unknown. During the 5 succeeding pregnancies she was delivered by our clinic as an unregistered case. Each time her Kolmer reaction was negative and the pregnancies terminated spon· taneously at twenty weeks, twenty-four weeks, twenty weeks, twenty-three weeks, and twenty-two weeks, respectively. The causes for these abortions are unknown. All of the fetuses were male, and all the puerperiums were normal. Physical examinations were negative except during her fifth puerperium when there was a slight diffuse thyroid enlargement. Last menstrual period Sept. 14, 1933. Pregnancy uneventful. The Kolmer re· action was again negative. Without warning or pain the patient bled a small amount with dark clots on the eighteenth of February, 19341 and in an hour labor pains started. Labor appeared to be progressing normally and at 12:45 A.M., Feb. 19, 1934, the head was delivered. There was no further progress and the pains became weak and irregular. Bleeding had ceased with the descent of the head and did not recur after its delivery. All efforts to deliver the remainder of the fetus by traction were unsuccessful. The patient was then examined vaginally and a large, eystic, tense fetal abdomen was discovered, One finger was easily forced into the fetal umbilicus, releasing a considerable amount of clear fluid under pressure. The remainder of the delivery was then easily accomplished without further delay at 1:30 A.M. on the same date, the patient being delivered of a twenty· eight-week dead male fetus measuring 35 em. in length and weighing (1,132 gm.) 2 pounds 8 ounces. Placenta, membranes, and cord appeared normal. Because of the unusual history of this case a Kahn test was performed on the blood of the patient's husband, the result being strongly positive. THE FE'I'US
GrO&S.-The fetus (Fig. 1), male, measured 35 em. in length. The head was cyanotic and separated from the vertebral column, though not from the body. The costal margins and xiphoid prQcess we:re on the same plane, and the thorax was markedly eompressed. The abdominal wall was cyanotic and quite redundant and wrinkled, having been punctured at the umbilicus and the ill8ertion of the umbilical cord destroyed. The genitalia appeared normal but the testes had not descended into the scrotum. The only other gross anomaly noted was bilateral talipes equino· varus. The anus was perforate. A purse-string suture was placed about the aperture in the abdominal wall. The large bladder was filled with formalin, 1,000 c.e. being necessary to fill the cavity without forcing the fluid under pressure. The entire fetus was fixed thus and frozen when a median saggital section was made (Fig. 2).
216
SAVAGE :
277
DYSTOCIA
No evidence was seen of intracranial injury, and no gross abnormalities were noted in the heart, lungs, or trachea. The abdomen had been perforated at the umbilicus and no evidence of a mem branous area in this region as described by Spicer and 8chwyzer in their cases could be found. The most striking· feature was the urinary bladder which had been so distended that it compressed all the abdominal viscera and caused deformity of the thorax (Fig. 2). The bladder was loosely attached to the abdominal wall. The peritoneum showed no signs of inflammation, and there was no ascites. The stomach, intestines, liver, gallbladder, pancreas, and spleen appeared normal grossly. There was no communication between tl•e intestinal tract and the bladder. The bladder was greatly dilated, in the midline, and ~~onsisted of a single c:n·ity spherical in shape with uniform ou tline. The wall Yaried in thickness from 1.48
Fig. 1.
Fig.!!.
rom. to 0.4 em. at the urethral orifice. The interior of the bladder was smooth and fairly even and measured 16 by 12 by 10 em. The ureteral orifices were 8 em. apart, and the right 4.5 em., and the left 5 em. from the urethral orifice. Beginning at the vesical orifice a probe passed easily through the urethra until a point 0.3 em. from the external urinary meatus was approached where it stopped. Proximal to this obstruction the urethra was markedly dilated measuring 0.4 em. in diameter. (Black thread in Fig. 2 is in the urethra). At the point of obstruc· tion there was a marked narr~wing of the lumen of the ure1;hra to 0.19 mm. measured in serial sections of the spongy urethra. No complete obstruction could be demonstrated, and no other abnormality of the urethra was noticed. The ureters were dilated, the right lllld left measuring 1.0 em. lllld 1.7 em. in diameter, respectively, at their widest points. They were tortuous but no obstruction was demonstrable in either. Fig. 3 shows the left kidney, adrenal, ureter, testicle, and the left half of the bladder.
278
AMERlCAK JOURNAIJ OF OBSTETRICS AND GYN.ECOLOf;Y
The kidneys were lobulated and showed no cysts. 'rhe pyramids were somewhat flattened and the pelves dilated, but the kidn ey substance did not appear to be affected. The rigM kidne,Y measured :).5 by ::! hy 1 em .. and its pelvis :I .5 by 0. i5 em.; while the measurements of the left kidnPy and its pelvis were :{ by 2 hy 1 em. and 1.6 by 0.9 em., rt>~pec tiY el y. The arlrenal gland~ appeared normal. The left and right kidneys, adrenals, and testes ex hibited normal histology. The bladder wall was 1.48 mm. in thickness aud appearetl normal histologically although there was evidence of hypertrophy in the muscular wall. Fat stain was negati\'e for intracellular as wrll a~ intercPl:ular fat. Sectiom of the liver Rhowed normal architecture; and in those stained by Levaditi 's method no Spirocheta pallida were found. Rugae in the left ureter had heen smoothed out and evidences of edema and muscular hypertrophy were pre~e ut. The ureteml wall was 0.2G mm. in thickness f1·om its mucous memhrane including the tunica adventitia. The right ureter exhibited the same pic.ture tu a les;;H degree. 'l'he rugae were slightly flat· tened and the lumen was large. The wall measured 0.18 mm. in thickness. Serial sections of th e distal half of the peni~ •1Pmonstratrd a murked steno~is of the
F'ig. 3.
spongy urethra at its distal extremity. At its narrowest point the lumen measured 0.19 mm . in diametPr . No actual obstruetion was found. The fluid was pale yellow in eolor and water-dear in transparency. Its reaction was alkaline to litmus and acid to phenolphthalein; and its hydrogen ion concentration by the colorimetric method was i .4. The specific gravity was 1.0075. By Marshall's urease method urea was found to be present to the extent of 0.36 per cent; while chlorides as sodium chlOI'idc were found to be 0.17 per cent by the Volhard-Arnold method. Albumin wa~ present to the extent of less than 0.003 per cent. There was no odor. Aretone, diaeetir- arid, hlood, and bile were absent. Microscopic examination of the centrifug·ed specimen showed two types of cells: 1. Epithelial cells of the squamous type were found in small numbers only, but were typical in size, shape, and grouping·. Dispersed throughout their protoplasm, but not in the nucleus, refractile droplets were seen which va1·ied in size the largest of which were about one micron in diameter. B,v suitable staining methods these droplets were seen to be lipoid in character. 2. A large number of cells of a second t,vpe were seen. They were larger than the polymorphonudear· leuco<',vte and showetl predominantly a large, single, round or horseshoe nucleus. In th!'st~ cells also the lipoid droplets were present but the
GORDON:
RPPTURED PREGNANCY IX CT.Ol-'1<:[) H1'Jlll\1E:..(TAHT HOHJ\
~~/!)
indivir!ual droplets were larger. These <'.l'lls stainP
In view of the absence of both sug·ar anr! larger quantitit>s of protrin it \Va~ felt that the possibility of the fluid's lJPing a tran~wlat<> wa~ ruler! out. Walther reports the findinf_;- of Ppitht>lial r•t>llH and fat droplPts in th!• tluid in his case hut records no intrrwellular lipoid !lropl<'t~. I wish to express my sincere appreciation to Drs . .J. M. H. Rowland and L. H. Douglass of the Department of Obst<'tri<'s: Drs. H. R. SpenC'er an
RUPTURED PREGNANCY IN THE CLOSED RUDil\TEN'J'AH.Y HORN OF A BICORNATE liTERFS ExTERNAL .MIGRATION oF THE SPERMATAZOON; URINARY SuPPREsswx F'OLLOWING TRANSJ'o'USION CHARLES
A.
GORDON,
l\I.D., F.A.C.S.,
BROOKLYN,
X. Y.
THIS ease of pregnancy in the closed aceessory or rudimentary horn of a. bicornate uterus is reported because of its rarity, and the nature of tlw transfuswn death, and to record a definite instance of t>xternnl o1· peritoneal migration of the sperma~ tazoon. M. S., German, aged twenty-eight, married eleven ntonth:l, was admitted to f:.:t. Catherine's Hospital on March 18, 1933, romplaining of ahrlominal pain. Her last menstrual period occurred on Oct. 12, 1932, with a preYiously rPgular 28/4 menstrual eycle without pain or diseomfort at :my time. She had sought no prenatal care in this, lH•r first, pregnarwy, and had b