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Full-Term Extrauterine Pregnancy, with Report of Three Cases
LEOOUX: FULL-TERM EXTRAUTERINE PREGNANCY
395
Both the preeclamptic cases gradually rose from 100 to 120 mm., not a marked increase but sufficient, with their other symptoms, to make the diagnosis very definite. I realize that I have not presented to you any new or startling facts, and possibly I have overemphasized figures. To me, however, prenatal care is such a vital subject, probably because in my clinic work I see so many tragedies which follow its negleet, that I have taken the risk of burdening you with statistics, both from the patient's and the physician's point of view, in order to stress the importance of seemingly minor matters. The task of keeping 250 such records, with their mass of details, is, I admit, an onerous one, but you will agree with me that to the conscientious physician one life saved from eclampsia will repay him for his self-imposed toil. 1121
MAISON BLANCHE BUILDING.
(For diB&ussiOtl see page 419.)
FULL-TERM EXTRAUTERINE PREGNANCY, WITH REPORT OF THREE CASES"" By LuciEN A. LEDoux, M.D., NEw ORLEANs, LA.
ULL-TERl\tl extrauterine pregnancy is a subject of unusual inFterest, not only on account of its comparative infrequency but also because of the varying aspects of its diagnosis and management. My first experience with the condition was in January, 1923, when I encountered a case on my colored obstetric service at Charity Hospital. Since that time, two other cases have been admitted on the same service and together they form the nucleus for some interesting observations. CASE 1.-B. W., colored female, age twenty-three, multipara. Admitted January 29, 1923. Previous history irrelevant. Last period January 16, 1922, duration ten days; usual duration five days. Patient was nauseated during latter part of February, felt life from middle of May to middle of October. Enlargement of abdomen began in March, and growth was rapid until November, when greatest size was attained. Since then there was a slow decrease in size. In November, after urination, she passed a lump of bloody, ftesh-like substance, about the size of her hand, and since that time there was a continuous pinkish discharge, fairly profuse. About two weeks before admission she began to have abdominal pains, usually dull in charaetet·, though occasionally sharp, accompanied by severe backache. There were chilly sensations also, hot ftushes, some nausea, and one spell of vomiting. At one time the pains were apparently definite labor pains, but these did not continue more than twenty-four hours. The breasts were enlarged and contained milk from March to November. Physical examination was negative except that the breasts were enlarged and Cl}ntained Mll}strum, and that the abdomen was the size and shape of a pregnant woman about at term. This enlargement was of a symmetrical, ovoid character, without rigidity or tender areas. No heart sounds made out, no fetal movements *Read at a meeting of the New Orleans Gynecological and Obstetrlce.l Society, November 19, 1925.
elicited. Vaginal ()xamination showed tlw os clos()d ami Roftened, and the entire eervix displaced posterioTly. The fundu~ was not made nut separate from the oyoid mase. X-rHy exanlinat ion tl id not •·outirm tlw •liag·uo~i~ of full-term <•xt muterinP preg-· lllllll'_l".
Under ether anesthesia another vaginal l'xamination was made, and a sound introdured, which prnetra.1rd the uterine <"'anal for thP n~n:1l di~tancP. confirming the diag1w~i~. .At this tinw al~o the fnnrlu:' <>nHlrl lw llHHl•• out dif-tinct from the ma~~. Laparotom;· wa~ the11 d01w throug-h n llll'•linn inr·i,;iou. .\ l!nge, c,vsth·. semisoli fr!'<', Pxcept on th<: left. Im·i~ion through the plac·<:nta, with sur·tioning of thr anmioti•• ftuid with tht• ma~~- .\ftrr partien~arly l'areful hemostasis the ahdonwn was r·loE patlwlogi<• r!.'port wa~ to thr rffed that t hi~ \Hi~ a •·aRe of 0\·arian pregnancy; nm inclinrd to ht'lif'Y<', hmwn'J', that it wn:; ~0enH(]ar,v in origin. ( '.\J.;E :!.~-J. P., •:olor,•ti ft•nmlP, age t 1\'t•Ht,l'·lli nt', JJrimiJ,a ra. .\,buittPd .XIarclt 10, 192:l. Previous histor." irre}eyant. La't l"'liod rady in July. 1[122, rxact date not known. Per~i~trnt wmiting spdl>< ~ re<'tum au.J tlw Yag·ina. in the culrlesac, as far down as the eoci'yx. The diagnosis was evidently a full-term abdominal pregnancy, with viable fetus. the position o ·eipitoposte1·ior and partially in('a1·errated. X-ray examination showed the pelvis to he amply large enough for the passage of the fetal head, and it wa~ the opinion of the staff that a relaxed ut'erim' wall had permitted the head to sink so low i11to the pelviR. The possibility of extrauterine pregnancy was considered. March 10, 192:!, ou examination, the hend \Yas found low in the culdesac and resting on the cocp;·x. The cervical os was found with great difficulty, and the cervix was pointing upwanl. Four days later thP external o~ was found two fingers dilated, The next olay appancntly definite all(! 110rmal labor began, ani! when examination, sewn·al hours latPr, d:sclosed that the pPrinenm was beginning to bulge, the patient was prepare!l for opPrnth"e delivery. Examination under ether anesthesia showed the ,·ertex pushing through the reetovagiual septum, with the eenix high up, anteriorly, behind the pubis and above the bladder, aucl the intemal os persistently closed. These findings seemed to establish the diagnosis of extrauterine pregnancy, and a median incision was therefore made. 'When the peritoneum was opened a dark brown omentum immediately bulged out, followed by a portion of the transverse colon. The uterus was not visible. 'W"llen the hand was introduced into the abdolli()n the fetus was found lying free in the cavity. the membranes ha-ring ruptur~d. Th<' ehild was somewhat
LEDOUX:
FT.:LL-TERM EX'l'R.\UTERlNE PREGNANCY
397
cyanotic, but cried as soon as delivered. The placenta and membranes, which were bile-stained, were found adherent to the right tube, broad ligament, cecum, and under surface of the liver. The fimbriated end of the right tube was the point of origin of the umbilical cord. The body of the uterus was in about normal position, purplish in color, soft, and about the size of a three months pregnancy. The adnexa were normal except that the tubes· were slightly enlarged. Removal of the placenta was deemed too hazardous and it was left in situ, with a firm pack about the base. Usual closure, with drainage at th0 lower ang:c of the wound. It ·should be noted that there was surprisi11gly little blood lost during this procedure. Convalescence was smooth until the tenth day after operation. The drain was removed on the fifth day, together with the pack, and the temperature was approximately normal. On the t enth day, howeYcr, there was a srvere chill with a trmperaturc ri"<' to 103 and a pulse of 120. From that time on ~t typical septic
Fig. 1.-Case 2. Child from a case of full-term extrauterine pregnancy. Picture taken when child was nearly two yea.r s old. Note supernumerary fingers and toes and webbing. course followed, with all the symptoms of general pe ritoniti~, an
398
THE AMERICAN JOURNAL OF OBSTETRICS .AND GYNECOLOOY
bleeding from the vagina. Admitted with diagnosis of probable abdominal preg· nancy. Physical examination negative except for abdominal condition. .E'etal parts dis· tinetly made out, with bulk of mass lying in ldt lower quadrant of the abdomen, and a smaUer mass extending to the right, about the height of a 3 months pregnant uterus. The fetal heart was distinctly heard to the left of the umbilicus and below. Vaginal examination showed a hard mass, presumably the head, between the vaginal wall and the symphysis at the normal position of the hlaflder. The cervix was soft and about one finger dilated. The fundus could not be made out. Examination under ether confirmed these findings. The mass on the right was identified as probably placenta; it was apparently continuous with the fetal ma~s on the left. Laparotomy through a 5 inch incision to tho left of the umbilicu;,. Incision of the sac and extraction of the fetu~. The presentation was face, one foot was pointing downward towards the pubis, the other was extended upward towards the splern. The anterior surface of the sac was covered by omentum. thr posterior by a thin, fibrous capsule. The placenta was attached partly to the right ~ide of the rectus muscle and to the right tube and broad ligament almost to the right cornu of the uterus. Its removal was obviously too dangerous to be con· sidered, therefore the cord was clamped and eut close to the base and ligated, and immediate closure without drainage was done. It should be noted also that both the large and small intestines were anemic looking and were adherent in several places hy an exudate resembling plasma. The patient was removed from the table in good condition. The fetus was very pale and respiration was infrequent and shallow. In spite of the usual methods of resuscitation there was no improvement, and the child died in ahrmt an hour. It was apparently normal in every way except that the nose was :flattened, probably from long pressure. Request for autopsy was refused. The motl_1er did well until late in the afternoon of the day of operation, when her pulse suddenly became rapid and grew progressively weaker. She died within a few hours. apparently :from shock due to internal hemorrhage. The abdomen was reopened and found to be filled with blooil clots.
The fact that these three cases occurred within two years, stimulated my interest in the subject and I investigated the records of Charity Hospital. Within the period from 1906 through November 1, 1925, 367 cases of extrauterine pregnancy were admitted, of which number 11 were full term, including the cases above reported. All were negro women. The ages ranged from twenty to thirty-eight years, 4 were primiparae and 7 multiparae. The value of a careful history is apparent. Most of these patients g-ave a history of apparently normal pregnancy, but in some few instances during the first trimester, symptoms were described which suggested the existence of extrauterine pregnancy. After this time the gestation approximated a normal one, and only at or near term did fresh symptoms recur. In all the cases except those in which living babies were delivered there was a cessation of fetal movements after term. Practically all reported the development of lactation, the passage of blood clots, or the presence of a blood-stained discharge, and severe abdominal pains, in most cases not resembling labor pains. Physical examination in all instances showed the tumor present, separate from the fundus uteri, which was usually displaced laterally.
LEDOUX:
FULL-TERM EXTRAUTERINE PREGNANCY
399
The fetal vertex usually encroached upon the culdesac. Abdominal examination showed the tumor to be unusually symmetrical, and the fetal parts quite near the skin surface. Three cases were reported past term, two being of twelve months duration and one of fifteen months. These cases differed from the others in that the patients all reported intermittent nausea, with or without vomiting, and progressive emaciation. In seven cases the preopm:ative diagnosis was correct. At operation most of the feti were found macerated. The placenta was usually located at or near the fimbriated end of the tube or in the culdesac. 'rhe uterus was uniformly reported to be the size of a three months pregnancy. Laparotomy was done in all instances, with the delivery of nine dead and two living feti. In both of the latter instances, it is interesting to note, the mothers died. There was one other maternal death. From my own three cases and the others whose records I have studied, I would make the following deductions: 1. Diagndsis is not always easy, as is evinced by the fact that only 7 of the 11 cases reported were diagnosed correctly. 2. The x-ray is of no diagnostic value other than furnishing confirmatory evidence that a dead fetus is present. 3. Laparotomy is the only safe method of delivery, particularly in consideration of the management of the placenta and the control of hemorrhage. 4. The prognosis is more favorable in cases in which the fetus is dead, because of the obliteration of the placental circulation. 5. The placental attachment often appears more formidable than it really is. 6. Drainage through the culdesac would seem logical and desirable. 7. Delivery of a living fetus is rare and is attended with grave maternal risk. REFERENCES
Walther: Med. Klin.1 1920, xvi, 799. Rosenblatt: Zentra.lbJ. f. Gynak., 1923, x1vii, 554-63. Suvansa: Lancet, 1924, i, 648-49. Tigert: Jour. Tenn. Med. Assn., 1922, xv, 132-35. llayd and Potter: AM. Jotm. OBST. AND GYNEC., 1923, v, 601·20. Craft: Lancet, 1922, il, p. 380-81. Leicester: Jour. Obst. and Gynec., Brit. Emp., 1921, xxviii, 295-98. 1109 MAISON BLANCHE BmLDING. (For dise11.ssi
395
Both the preeclamptic cases gradually rose from 100 to 120 mm., not a marked increase but sufficient, with their other symptoms, to make the diagnosis very definite. I realize that I have not presented to you any new or startling facts, and possibly I have overemphasized figures. To me, however, prenatal care is such a vital subject, probably because in my clinic work I see so many tragedies which follow its negleet, that I have taken the risk of burdening you with statistics, both from the patient's and the physician's point of view, in order to stress the importance of seemingly minor matters. The task of keeping 250 such records, with their mass of details, is, I admit, an onerous one, but you will agree with me that to the conscientious physician one life saved from eclampsia will repay him for his self-imposed toil. 1121
MAISON BLANCHE BUILDING.
(For diB&ussiOtl see page 419.)
FULL-TERM EXTRAUTERINE PREGNANCY, WITH REPORT OF THREE CASES"" By LuciEN A. LEDoux, M.D., NEw ORLEANs, LA.
ULL-TERl\tl extrauterine pregnancy is a subject of unusual inFterest, not only on account of its comparative infrequency but also because of the varying aspects of its diagnosis and management. My first experience with the condition was in January, 1923, when I encountered a case on my colored obstetric service at Charity Hospital. Since that time, two other cases have been admitted on the same service and together they form the nucleus for some interesting observations. CASE 1.-B. W., colored female, age twenty-three, multipara. Admitted January 29, 1923. Previous history irrelevant. Last period January 16, 1922, duration ten days; usual duration five days. Patient was nauseated during latter part of February, felt life from middle of May to middle of October. Enlargement of abdomen began in March, and growth was rapid until November, when greatest size was attained. Since then there was a slow decrease in size. In November, after urination, she passed a lump of bloody, ftesh-like substance, about the size of her hand, and since that time there was a continuous pinkish discharge, fairly profuse. About two weeks before admission she began to have abdominal pains, usually dull in charaetet·, though occasionally sharp, accompanied by severe backache. There were chilly sensations also, hot ftushes, some nausea, and one spell of vomiting. At one time the pains were apparently definite labor pains, but these did not continue more than twenty-four hours. The breasts were enlarged and contained milk from March to November. Physical examination was negative except that the breasts were enlarged and Cl}ntained Mll}strum, and that the abdomen was the size and shape of a pregnant woman about at term. This enlargement was of a symmetrical, ovoid character, without rigidity or tender areas. No heart sounds made out, no fetal movements *Read at a meeting of the New Orleans Gynecological and Obstetrlce.l Society, November 19, 1925.
elicited. Vaginal ()xamination showed tlw os clos()d ami Roftened, and the entire eervix displaced posterioTly. The fundu~ was not made nut separate from the oyoid mase. X-rHy exanlinat ion tl id not •·outirm tlw •liag·uo~i~ of full-term <•xt muterinP preg-· lllllll'_l".
Under ether anesthesia another vaginal l'xamination was made, and a sound introdured, which prnetra.1rd the uterine <"'anal for thP n~n:1l di~tancP. confirming the diag1w~i~. .At this tinw al~o the fnnrlu:' <>nHlrl lw llHHl•• out dif-tinct from the ma~~. Laparotom;· wa~ the11 d01w throug-h n llll'•linn inr·i,;iou. .\ l!nge, c,vsth·. semisoli
LEDOUX:
FT.:LL-TERM EX'l'R.\UTERlNE PREGNANCY
397
cyanotic, but cried as soon as delivered. The placenta and membranes, which were bile-stained, were found adherent to the right tube, broad ligament, cecum, and under surface of the liver. The fimbriated end of the right tube was the point of origin of the umbilical cord. The body of the uterus was in about normal position, purplish in color, soft, and about the size of a three months pregnancy. The adnexa were normal except that the tubes· were slightly enlarged. Removal of the placenta was deemed too hazardous and it was left in situ, with a firm pack about the base. Usual closure, with drainage at th0 lower ang:c of the wound. It ·should be noted that there was surprisi11gly little blood lost during this procedure. Convalescence was smooth until the tenth day after operation. The drain was removed on the fifth day, together with the pack, and the temperature was approximately normal. On the t enth day, howeYcr, there was a srvere chill with a trmperaturc ri"<' to 103 and a pulse of 120. From that time on ~t typical septic
Fig. 1.-Case 2. Child from a case of full-term extrauterine pregnancy. Picture taken when child was nearly two yea.r s old. Note supernumerary fingers and toes and webbing. course followed, with all the symptoms of general pe ritoniti~, an
398
THE AMERICAN JOURNAL OF OBSTETRICS .AND GYNECOLOOY
bleeding from the vagina. Admitted with diagnosis of probable abdominal preg· nancy. Physical examination negative except for abdominal condition. .E'etal parts dis· tinetly made out, with bulk of mass lying in ldt lower quadrant of the abdomen, and a smaUer mass extending to the right, about the height of a 3 months pregnant uterus. The fetal heart was distinctly heard to the left of the umbilicus and below. Vaginal examination showed a hard mass, presumably the head, between the vaginal wall and the symphysis at the normal position of the hlaflder. The cervix was soft and about one finger dilated. The fundus could not be made out. Examination under ether confirmed these findings. The mass on the right was identified as probably placenta; it was apparently continuous with the fetal ma~s on the left. Laparotomy through a 5 inch incision to tho left of the umbilicu;,. Incision of the sac and extraction of the fetu~. The presentation was face, one foot was pointing downward towards the pubis, the other was extended upward towards the splern. The anterior surface of the sac was covered by omentum. thr posterior by a thin, fibrous capsule. The placenta was attached partly to the right ~ide of the rectus muscle and to the right tube and broad ligament almost to the right cornu of the uterus. Its removal was obviously too dangerous to be con· sidered, therefore the cord was clamped and eut close to the base and ligated, and immediate closure without drainage was done. It should be noted also that both the large and small intestines were anemic looking and were adherent in several places hy an exudate resembling plasma. The patient was removed from the table in good condition. The fetus was very pale and respiration was infrequent and shallow. In spite of the usual methods of resuscitation there was no improvement, and the child died in ahrmt an hour. It was apparently normal in every way except that the nose was :flattened, probably from long pressure. Request for autopsy was refused. The motl_1er did well until late in the afternoon of the day of operation, when her pulse suddenly became rapid and grew progressively weaker. She died within a few hours. apparently :from shock due to internal hemorrhage. The abdomen was reopened and found to be filled with blooil clots.
The fact that these three cases occurred within two years, stimulated my interest in the subject and I investigated the records of Charity Hospital. Within the period from 1906 through November 1, 1925, 367 cases of extrauterine pregnancy were admitted, of which number 11 were full term, including the cases above reported. All were negro women. The ages ranged from twenty to thirty-eight years, 4 were primiparae and 7 multiparae. The value of a careful history is apparent. Most of these patients g-ave a history of apparently normal pregnancy, but in some few instances during the first trimester, symptoms were described which suggested the existence of extrauterine pregnancy. After this time the gestation approximated a normal one, and only at or near term did fresh symptoms recur. In all the cases except those in which living babies were delivered there was a cessation of fetal movements after term. Practically all reported the development of lactation, the passage of blood clots, or the presence of a blood-stained discharge, and severe abdominal pains, in most cases not resembling labor pains. Physical examination in all instances showed the tumor present, separate from the fundus uteri, which was usually displaced laterally.
LEDOUX:
FULL-TERM EXTRAUTERINE PREGNANCY
399
The fetal vertex usually encroached upon the culdesac. Abdominal examination showed the tumor to be unusually symmetrical, and the fetal parts quite near the skin surface. Three cases were reported past term, two being of twelve months duration and one of fifteen months. These cases differed from the others in that the patients all reported intermittent nausea, with or without vomiting, and progressive emaciation. In seven cases the preopm:ative diagnosis was correct. At operation most of the feti were found macerated. The placenta was usually located at or near the fimbriated end of the tube or in the culdesac. 'rhe uterus was uniformly reported to be the size of a three months pregnancy. Laparotomy was done in all instances, with the delivery of nine dead and two living feti. In both of the latter instances, it is interesting to note, the mothers died. There was one other maternal death. From my own three cases and the others whose records I have studied, I would make the following deductions: 1. Diagndsis is not always easy, as is evinced by the fact that only 7 of the 11 cases reported were diagnosed correctly. 2. The x-ray is of no diagnostic value other than furnishing confirmatory evidence that a dead fetus is present. 3. Laparotomy is the only safe method of delivery, particularly in consideration of the management of the placenta and the control of hemorrhage. 4. The prognosis is more favorable in cases in which the fetus is dead, because of the obliteration of the placental circulation. 5. The placental attachment often appears more formidable than it really is. 6. Drainage through the culdesac would seem logical and desirable. 7. Delivery of a living fetus is rare and is attended with grave maternal risk. REFERENCES
Walther: Med. Klin.1 1920, xvi, 799. Rosenblatt: Zentra.lbJ. f. Gynak., 1923, x1vii, 554-63. Suvansa: Lancet, 1924, i, 648-49. Tigert: Jour. Tenn. Med. Assn., 1922, xv, 132-35. llayd and Potter: AM. Jotm. OBST. AND GYNEC., 1923, v, 601·20. Craft: Lancet, 1922, il, p. 380-81. Leicester: Jour. Obst. and Gynec., Brit. Emp., 1921, xxviii, 295-98. 1109 MAISON BLANCHE BmLDING. (For dise11.ssi