Eclampsia and ovarian pregnancy

ECLAMPSIA (2.

B.

PRIDE,

LMB.,

AND

MORG.UCTOWN,

OVARIAN VA.,

TV. IIXICH&~OND,

PREGNANCY* AND

&I.

PIERCE

M.D.,

RUCKER,

VA&.

CAREFUL search of the various medical indices failed to reveal a similar case. only six instances of extrauterine pregnancy with A eclampsia have been reported and these have all been tubal or abdominal pregnancies. The first case was reported by Spiegelberg.’ The patient was a 32year-old para iv at term. She had five convulsions before her admission to the clinic. She was edematous, with scanty, dark-colored urine that boiled solid. F&al heart rate was 128. The cervix was open and pushed to the left. The internal OSwas closed. The baby was in the R,.o.A. position. The patient had three more convulsions after admission. She was given ergot and an at,tempt was made to inIt met with sonic obstruction and troduce a catheter into the uterus. the examining finger brought back a piece of decidual tissue. The patient died two days later and autopsy showed dark 1)loody fluid in the peritoneal cavity and a beginning peritonitis. The fetus, a male, weighed 3,000 Gm., was entirely within the Fallopian ~LI~W which showed some sign of rupturing in one place. The uterus was 12 cm. long. The second was reported from Maygrier’s Clinic in Paris by 11. Lafon.z The patient was a 27-year-old para iii whn early in her pregnancy (J~tly, 1895) had severe abdominal cramps that confined her to bed. In August she had a hemorrhage while in t,hc hospital. In September she had edema of the lower extremities and again entered the hospital where a diagnosis of pregnancy complicated by tumor was made. on February 10 she bled a little and two days later began to have convulsions (18 in all). On February 13 Maygricr made an internal cxamination and diagnosed the extrauterine pregnancy with living baby. The fits continued and the woman died undelivcrcd. The diagnosis of extrauterine pregnancy was confirmed by post-mortem colpotomy. The third case was reported from Denmark by HoW (1896), who was called after a ~OLII~ girl had lost consciousness and was having convulsions. He found the uterus to be the size of a six months’ pregWUKy. The urine contained a quantity of albumin. He made an unsuccessful attempt, to induce labor by injecting hot water. The convulsions stopped and the patient improved. Five months later a fluctuating abscess formed which opened into the vagina. ,Small fetal bones escaped. The abscess also opened into the intestines. The first, opening was enlarged and the head and most of t,he f&al skeleton wcrc evacuated. The fistulas closed rluickly and recovery ensued. Schumann4 reports the case of a patient, upon whom E. P. .l)avis operated. The patient was a primipara aged about 30 years. Her pregnancy had proceeded normally unt,il between the seventh and eighth month, when after albuminuria had been prcseni for over a wc& the patient, had scvcral cclamptic convulsions. She rc~~vcrcd from this seizure and, although she had some abdominal pains, labor did not comboon. The abdo*Read at the Fifth cians :~n~l Cl-necologists,

Annual Meeting Atlanta, Ga.,

of the South Atlantic Association February ti and 7, 1942.

575

of

Obstctri-

576

AMERICAN

JOURNAL

OF

OBS’l’ETRIC’S

AND

GYNECOLOGY

men became smaller and fetal movements could not be felt. Her general health became improved, but an abdominal tumor remained. Bimanuai examination gave the impression usually seen in fibroid tumors of the uterus or abdominal pregnancy with retained fetus. The abdomen was opened and a dead fetus of about eight months was in the abdominal cavity. Its sac was attached to the upper portion of the uterus. TIw placenta was attached to the right broad ligament. The patient ma& a good recovery. The fifth case was reported by E. Allen.5 The patient was a. twent,yone-year-old Negro primigravida. The abdominal pregnancy was diagnosed and, while the patient was awaiting term? she had three convulsions. The baby, delivered by laparotomy, weighed four and onefourth pounds. It cried lustily but died in eight hours. The mother had a psychosis, discharged some placental tissue through the upper end of the wound, but eventually recovered. The sixth case was reported by Ewart.G The patient, 41 years of age, was in the eight,h month of her sixth pregnancy. Her fifth pregnancy She had three sixteen years previously was complicated by edema. The presentation was a breech and an external version convulsions. was attempted. Four days later induction of labor was attempted with bougies but, was unsuccessful. A month later laparotomy revealed the The patieut died on thtl true condition, i.e., abdominal pregnancy. third postoperative day. Aut,opsy showed an internal hemorrhage from the placental side. Our case is, so far as we can find, the sevent,h extrauterine pregnanq’ to be complicated by celampsia. Furthermore, it is the only ovarian pregnancy that has been reported with such a complication. Mrs. D. A. W., aged 30 years, pregnant for the first time, was due on May 12, 1940. The patient was an only child. Her family history was negative. The patient had scarlet fever at thirteen years. Except for an occasional attack of “flu” there had been no ot,her illness. She was married in 1936. Menses began at, eleven, occurred every 26 to 28 days, and lasted five days. She had leg ache sometimes when she menstruated and a leu(aorrhca of some years’ st,anding. In May, 1939, she flooded two weeks after a regular period, passed clots, and had some cramps. One of us saw her at this time and considered it a functional bleeding. The patient mcnstruat,ed last ou August 5, the flow lasting two days. From September 9 until some time in November the patient had a little bloody vaginal discharge which w:\s never as much as an ordinary menstruat,ion. She was a little nauseated and had canker sores in the mouth. Pelvic esamination showed what was thought to be an enlarged retroverted uterus. Xo lateral masses were palpated and the examina,tion The Friedman test was positive. On clicitated no pain or discomfort,. December 1, her face and hands began to swell and she had an attack of severe abdominal pain which was relieved by morphine. This was ihe only attack of severe pain. There was some dysuria before Christ,rims anal, when on h(>r feet., she experienecd some lower abdominal dis(domfort On .January 23 she 1~1 i hr(lc convulsions and was “out,?” as 11~ pat,it>nt expressed it? for six da>,s. At, this time she was taken to the hospital. Her blood pressure lvas 2lO,U20 arid t,be urine was loaded \vith albumin. The treatment consist01 of magnesium sulfat,e by montl1 and once by vein, and sodium amytal.

I’RIDE

AND

RtJCKER:

ECLAMI’SIA

AND

OV-4RL1X

PREGNANCY

577

Except for dimness of vision the patient recovered compIetely from the toxemia. The blood pressure became normal and the albumin disappeared from the urine. Her highest temperature was IOl.2O F. on January 25. At that time her pulse was 132. Since then her tempcrature has been normal. Four attempts were made to induce labor. Each time she had a few cramps when the packing was removed. At the third a.t.tempt, Feb. 12, 1940, some material was removed which the pathologist reported to be placental tissue with decidual cells and columnar epithelium. However, no villi were seen. The patient had quite a hemorrhage at this time and a small transfusion was given. At this time some doubt arose as to whether the fetus was within the uterus. A Jqriedman test was repeated and a soft tissue x-ray was taken in hopes of demonstrating the uterus. The Friedman test was negative and the x-ray showed a small fetal skeleton lying t,ransversely just above the

Fig.

l.-Gestation

sac opened,

showing

inside

surface

of sac

and

entire

fetus,

Jmbes. No uterine shadow could be seen. The patient was in excellent condition except that she could not read. When she walked about there was a small amount of uterine bleeding. Urine was negative. Blood count was red cells 3,460,OOO; leucoc.ytes, 13,500 ; polymorphonuclears, 77 per cent; hemoglobin, 70 per cent; blood pressure, 120/86. Heart The abdomen was rounded and there and breath sounds were normal. was a mass that reached halfway to the umbilicus. Vaginal examination showed marked pigmentation of the mucosa. There was no vaginal discharge. The introitus was nulliparous. The cervix was just back of the pubis. It was soft, uneffaced, and admitted a finger for about an inch. The pelvis was filled with a firm unmovable mass. Examination caused the pat,ient no pain. The abdominal mass could not be outlined by bimanual examination, but seemed to extend about halfway io the umbilicus. The discussion of the case centered about the question as to whether the fetus was within or without the uterus. The negative Friedman

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OI3SI~I~:‘lTUIX

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Gl-NECOLOGS

test indicated that the placenta had ceased to function and, thercfo]*c, thcrc wa.s no question but that the fetus was dead. The fact, that tlitS uterus did not empty itself and would not be made 10 empty it,self, KM the only indication of an extrauterine pregnancy. The contracted uterine body was not visualized on the soft tissue plate. Tissue which had been removed from within the uterus was reported a~ placentas t,issue by the pathologist, but this was not conclusivt~ because nn villi wcrc found. The prescncc of dtGdua1 ~~11s.according tn TcTAinde, is WC fillilll~ il~lTCd Or1 tll? not absolute proof that pregnancy wists. therapeutic test of giving the patient &rin for five or six days. 1 f thlr dead fetus lay within the uterus, the t>strin would in all probabilii~ activate the uterus, especially as the placenta had b(>en shown to bc iliactive. If the estrin failed, a laparotjomy should be done. An abdominal operation was performt>d April 13, 1940. The uterus was found to be slightly cnlargcd, flatt,ened. an<1 resting on top of a large mass, which measured 15 bv 9 $i 1)~ S:vi MM. The mass was sy111metrical and semisolid. It occup&l th(l ~~~l-d~-sacand (lst,endecl to 11~ umbilicus. No free blood was prcscnt in tile abdominal cavity. Thp ltbf( tube and ovary were normal. In one placr t,ht>r(l was a small, thinnedotlt, discolored arca in the gestation wall. This condit,ion was caus~i, no doubt, by the accidental rupture of th(a utrrine wall and the gestat,ion sac b\l the sound on Feb. 12, 1940. The mass, attachtad to lhc right side & the uterus by a long pedicle, was cqsil>- freed by blunt dissoctio~l and brought, up into the wound. ITad one not known that a pregnanqy existed, he would have thought this to btl an ovarian tumor or cyst on a. long pedicle. The right uteroovarian ligament was identified. anal t lttl right, tube appeared normal, except at the distal end, where it was a(lherent to the mass. The right, cmwy would not 1~ seen. l>ilrge hloo~l vessels wcrc present in th(l pedicle, whi(*h ex~endcd from the \lterlls t II I he mass, and were the only source from whi(*h !hc gestation sii(ar~~c~~ivt~d its b100d supply. The YK+SCIS were ligattad a?ld 11~~sac WCIS r~n~o~t~daft tat* clivision of the pedicl~~. The recovt’ry was l~nc~vmtful. The pi~ti(~~~t W:IS dischargt>d from the hospital on Jla>e 3. 1940. ~1ICROSCOl’I~’ S’l~~T~ll~:S Wc are indebted to l)rs. C. Cm’.FcntoL~ and (i. S. IJodds of the. l-niversity of West Virginia for the following (lcs<*ription of the spe~im~~~~ : *’ Four samples from different regions 01: the sacashowed the following microscopic struct,ure : The greater portion of ih(; thickness of t,tle wa]] from t,hc inner surface was of nccrot iv tissue with much blood. Hcr(b and there a necrotic villus was seen. The o~~t~rnlost, layer it’ the wall (I 1111~~. and less in thickness) was not, necrot,ic antI shmwl &finite o\~at*iatl dIYIc+U~c. The stroma was of conncctivcl tiss~~l~,wcl] vas(att]arize(l, antI rich in spindle-shaped cells, a histologist pict ULY strongly snggesti~~~ 01’ lhe ovary. Definitely diagnostic wcrc s(~atterc(l ovarian fol]ic]es in \-auious stages of growth, Srom those of small size to large ones with strliv. ture like the usual Ciraafian follic1c.s (Fig:. 2 and 3). Ljl[ of the largckl follicles were greatly flattened in a positron parallel to the surface of the sac, CM would he expected whm 111(t ovilry h;~cl l~~~~lergonp ~r~i~l distention. ( Fig. 2 shows :I portio~i of :I felt j(altsjvhi~lj m~~asurc~l4,000 lye 70 mirrons.) ” ” The larger f01li~les were undcrqoi~~g >~tr~si~~,as SIIOWI~1)~.dcgcn<~~~:Ltion of the gra,nulosa ~~11sand by th(l presenctl of polygonal iheca, lutcin c&s among the spindle-shaped cells of the theca folliculi (Figs. 2 and 3).

No germinal

cpithelium was obscrvcd at any 01 the places sampled, but at one place a n~csothclial covering was seen. “Sections from lhc wall in the placental artba sliowcd many chorionic villi. The superficial zone in these sections was somewhat suggestive of ovarian stroma, but not conclusively so. One probable ovarian follicle of moderate size was seen. On the whole the microscopic studies are sufficient to demonstrate that ovarian tissue was present in t,he outer stratum of the sac at the several places sampled.” Thus the case fulfills all the essential criteria for ovarian pregnancy, viz., (1) the gestational sac occupied the position of the ovary; (2) the tube on the affected side

Fig.

Fig.

2.

Fig. Z.-Part of large ovarian follicle: losum; TF, them folliculi; TL, them power. ) Fig. 3.-Shows wall of large ovarian inogwFrajny them lutein cells and an early

FC, lutein follicle follicle

follicular cells.

3.

cavity.: SG, (Photonwxograph

and adjacent ovarian (Photomict’ograph (-@F).

stratum grantunder high stmna

under

includhigh

was intact and showed no evidence of gestation ; (3) the gcstational sac was connected with the uterus by the uteroovarian ligament ; (4) definite ovarian tissue was found in the wall of the sac in different places; and, (5) there was placental tissue within the ovarian stroma. DISCUSSION

The rarity of the combination of eclampsia and ovarian pregnancy In the first place, eclampsia seldom occurs in the is not surprising. first half of pregnancy. Standers says that fewer than 60 cases have been reported. In the second place, ovarian pregnancy is rare and such a The same pregnancv rarely extends into the second half of pregnancy. can be said for extrauterine pregnancy as a group. We know that the presence of the fetus is not necessary in order to have e&mph but that the presence of the placenta is necessary. It

tirould seem that nature is performing an experiment for us I o see il t.he lo~at,ion of 111~pla~nia, made any ~liffercn~~~~.ln Spiegelberg’s cssc the placenta W~LSwithin the tuh(h. 11~our case it was within the ova.ry. In Allen, Schumann, and #wart ‘s it W&S in the ahdolliilld Cavity alld rJl’(‘sumably that was trne also in Hoist’s and LafoIl-Maygrier’s cases. Eclampsia is possible, regardless of where the placenta is loeatctl. The next question is the relative frequency of eclampsia when the placenta The frequency of is implanted in or on tissues outside the uterus. c~~lampsia is variously skted as once in 300 to 500 cases. If 111~S~III~~ frequency obtained for ectopic pregnancy, it. would mean Ihat I ht~r(~ leave been from 2,100 to 3,500 cases of mispJaced gestat,ioli ol’ al ltwsi five months’ duration. Ucrtainly that many have not been reported. (Yinically this group of 7 extrauterine pregnancies with eelan~lka is interesting. Most of the patients complained of the usual symptoms oi rctopic gestation, i.e., abdominal pains and vaginal bleeding. The IOS
2. Lafon,

3. Holst,

Paris

These.

406, I8io. de quelques

formes

anormales

d ‘eclalnpsie,

1899.

Akxan
4. R.,

SJI,

York,

1921,

1241. D.

5. Allen, Edward: AM. .J. OBST. & GYXE~~. 25: i>3, 1933. 6. Ewart, I. B.: New Zealand If. .J. 33: 48, 1934. 7. TeLinde, Richard W., and Henrikson, Erb: AM. .T. 0~s~. & GYXEC. 39: 1940. 8. Stander, 1: Chapter H. J.: 8, Gynecology 24. and Obstetrics, Hagerstown, 1937, W. F. Prior p.

139i. Apple.

732, Co.