INTRAUTERINE
RUPTURE
OF A VELAMENTOUS
UMBILICAL
CORD+ BY
GEO.
W.
KOSMAK,
M.D., NEW YORK, N. Y.
T
HERE is no gainsaying the fact that improvement in obstetrical methods and procedures has largely diminished maternal morbidity and mortality. Any one whose obstetrical experiences extend back over a period of twenty years can bear personal witness to the reduction in the number of serious obstetrical complications that are referred to a hospital for final delivery or treatment or are met with in consultation practice. But there is still a large group of fetal anomalies before which the obstetrician stands helpless. This includes mainly those accidents associated with fetal growth and development that cannot be detected in advance by any known methods that would result in the saving of the life of the child. Among these, attention may be directed to anomalies of the cord either in its development or in its accidental malposition, and it is to an example of this that I desire to call your attention. CASE&PORT.-MRS.M. F. E., aged thirty, married July 1, 19,220. First consulted me on April’ 16, 1921, with a history of having had her last regular period January 23 to 28. She flowed slightly for two days in February. The patient’s previous history was good. She appeared well nourished, inclined to corpulency and stated that she had gained twenty pounds since her marriage. It was difficult to map out the uterus by bimanual examination on account of the thick abdominal wall but a rather hard rounded mass was definitely palpable in the left adnexal region which was thought to be a tumor of the ovary or possibly a uterine fibroid. A month later the uterine enlargement was definitely palpable. There were no subjective signs of pregnancy noted, no morning sickneq no breast secretion. During the summer the patient began to notice swelling of the hands and feet and she felt life for the first time June 15th. The blood pressure was never above l-10, but beginning with the first week of September the patient complained of constant drowsiness which bothered her to such an extent that she was unable Aside from pyrosis no other symptoms to attend to her ordinary household duties. were complained of. The urine at this time showed slight traces of albumin but no casts, with a depressed gravity and a corresponding relative amount of urea. The blood picture was normal. Intensive tingling in the hands and feet together with indefinite neuralgic pains made the patient very uncomfortable. The puffiness of the hands and the edema of the legs and abdominal wall became more marked and as no response followed ordinary dietetic and eliminative measures, I sent the after a week’s rest in bed with thorough patient to the Lying-In Hospital where, catharsis, dietetic restrictions, colonic irrigations and hot packs, a rapid improvement occurred. The urinary picture at this time showed little change, slight to moderate traces of albumin and a low specific gravity with occasional granular *Read at the Forty-seventh ington, D. C., May 1-3, 1922.
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casts. The blood pressure at this time began to go up slightly and varied from 146 to 150. Although the pregnancy had been calculated as due about October 30, the patient at this time was evidently not over eight months. On November 15 I ordered two ounces of castor oil as a cathartic and also with the hope that labor might be induced, as the patient had become rather uncomfortable and the abdominal enlargement rather extreme. No pains resulted and the patient was quite comfortable after taking the oil. While engaged in playing cards about six hours after taking the oil she noticed a sudden discharge of blood, no pains were present. I saw her about an hour and a half later and found the bed clothes saturated and internal vaginal examination showed the vagina full with large clots. Patient’s general oondition was good although she appeared rather pale and the pulse was somewhat rapid. She stated that she had not felt any life since six o’clock. The cervix was rigid, high, thick, one finger dilated and no presenting part could be felt. The fetal heart was not heard. A tentative diagnosis of premature separation of the placenta was made and the patient was sent to the Woman’s Hospital. Notwith-
. /’
Fig. l.-Diagrammatic representation of plaenta, showing rupture The right half of the sketch shows the posibion sels on the left. course of the blood from the separated placenta !a).
of velamentous cord VWof the placenta and the
standing the fact that the fetus was probably dead and that the hemorrhage had lessened at the time of admission I felt it advisable to deliver immediately by cesarean section in view of the long rigid cervix, insufficient dilatation and the fact that the patient had already lost considerable blood with a possibility of a recurrence of the hemorrhage. The cesarean operation was done by the Davis technic. After incising the uterus the hand was introduced and the membranes swept free. The liquor amnii which was evacuated was mixed with fresh fluid blood. A part of the placenta projected into the wound and the organ itself was attached along the right side of the uterus extending down to the lower uterine segment. The child was extracted by the feet. There were no pulsations evident in the cord. The baby appeared exsanguinated and had evidently died recently. After extracting the placenta and membranes the uterine wall was sutured in layers The uterus contracted well and presented at least one-half with plain catgut. dozen fibroid nodules projecting from the surface. One of considerable size in the anterior wall was included in the incision. A tumor as large as a hen’s egg which projected from the surface of the anterior wall and appeared to be breaking down
KOSY:II<
:
INTRAUTERINE
RIJPTURE
OF
CORD
621
was clamped and excised from its attachment by a broad p&We. The abdominal wall was then dosed in layers and the patient returned to bed in good condition, appearing rather pale but responding satisfactorily to treatment. Further examination of the fetus showed that it was well nourished, the subcutaneous fat slight, that it was very much exsanguinate& The placenta itself was quadrilateral with the cord attached to the upper pole in the form of a velamentous insertion. A rupture had taken place through two of the separated vessels and from this site the fatal hemorrhage had evidently taken place. In addition an area of about two finger-breadths at the upper pole presented several infarcts and had evidently separated from the uterine wall. (Fig. 1.)
In commenting on this case we may state in summary that we are dealing with a primipara in the eiihth month of her pregnancy who had gone through a mild degree of toxemia of the nephritic type which had responded favorably to treatment. The placent,a presented infarct formation which is often associated with such toxemia and which undoubtedly led to the separation of the organ. It is probable that the uterine contractions induced by the castor oil contributed to the separation of the placenta and that this likewise resulted in the laceration of a portion of the velamentous cord. The sudden gush of blood noted by the patient probably came from the separated placenta although this blood apparently had to travel from the upper pole of the uterus t,o the cervix between the fetal membranes. There was insufficient dilatation of the cervix and no evidence of placental separation at the lower pole which would have produced this amount of bleeding. Strange to say, the patient, did not experience the pain usually associated with premature separation of the placenta. The baby of course died from asphyxia as the result of intrauterine hemorrhage from the cord. It will be noted in this case, contrary to the usual findings, the velamentous cord was inserted at. the upper pole of the placenta, whereas in the cases generally reported this anomaly was present in the region of the cervix and rupture occurred as the cervix dilated. In this respect our case differs from those ordinarily observed. The patient made an uneventful recovery, the wound healed by primary union and there was no shock. Subsequent urine examination disclosed nothing abnormal. Knapp* described a twin la,bor in which both fetuses were lost from this accident, the anastomosis between the cords contributing to the resalt. Peiser3 reports a case in a para-iii with two previous normal labors. Her last was spontaneous and the baby was born dead and examination showed rupture of a velamentous cord. Miranoff, reporting the incidence of this complication in the material of the Dresden Frauenklinik noted a frequency of 5 per cent velamentous cords among twin pregnancies and 0.57 per cent in all labors. The occurrence has been variously estimated by several observers as occurring in from 0.4 to 0.9 per cent of all cases. The diagnosis of the condition and the delivery of a living child is rather unusual. Ahlfeld has had two cases. Hartman* reports a case
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associated with a lateral placenta previa in which he did a version with the delivery of a living child. The placental insertion of the cord is subject to considerable variations, most of which are without pathological significance. The presence of the so-called velamentous insertion of the cord must always, however, be regarded as a source of danger to the child. In this anomaly the umbilical vessels become separated at varying distances from the placenta and take a course between the amnion and chorion before reaching their placental termini. This means that when labor begins a rupture of the membranes occurs in the immediate vicinity of these isolated vessels, especially if they happen to be located over the internal OS, the umbilical artery or the veins as the case may be, are torn through with the loss of the fetus from hemorrhage, or the advance of the presenting part may compress these vessels and produce fetal asphyxia. Whether these babies are less well developed or whether premature labor may occur as the result of this anomaly, the outcome is doubtful. A considerable number of cases of fetal death from this source have been recorded among them one by Williamson’ in which the cord ruptured at the upper pole of the ovum when the patient went into the second stage and .fetus died notwithstanding a rapid forceps extraction. Williamson believes that if the diagnosis is made early in labor, cesarean section is indicated but after rupture the chances of securing a living child hardly warrants this exposure of the mother. The frequent association of velamentous cord insertion with placenta previa should lead us to bear this complication in mind. Again, irregular bleeding at the end of the first stage of labor should also lead us to suspect this condition where a lateral placenta was believed to be present and none found on careful examination, especially where the presenting part is well engaged. As for the methods of treatment, it is radical to suggest a cesarean section in order to obviate the long delay incident to complete dilatation of the cervix but where the accident occurs in a primipara with such a severe hemorrhage as in the case herewith reported, due to another cause, cesarean section would be the only method of choice. It is claimed that velamentous insertion of the cord is always associated with placental a,nomalies such as previa and succenturiata and also infarcts as noted by De Lee.5 Multiple fetuses, twins and triplets, are also reported as accompaniments of this cord anomaly. The diagnosis of the condition is only possible if the pulsating vessels can be felt within the circle of the dilating cervix over the bulging bag of waters. In such cases it may be possible to rupture the membranes between the vessels after dilatation is complete and then deliver the child as rapidly as possible otherwise pressure will produce asphyxia. Where the cervix is not yet fully dilated a Voorhees or other soft rubber bag may be carefully inserted so as not to produce a premature rupture
BECK
:
INTERFERENCE
AFTER
TWENTY-FOUR
HOURS
OF
623
LABOR
of the membranes, but fetal asphyxia is readily possible in such cases. In primiparae, however, such as the present case, with long rigid cervix, even if a diagnosis had been made, such slow methods would have been of no avail. Where the cord is inserted at the upper pole of the uterus, as in this instance, a diagnosis by palpation is, of course, impossible. REFERENCES (1) Jour. Obst. and Gynec., Brit. Emp., 1912, p. 203. (2) Arch. f. Gyniik., 1896, ii, No. 3. (3) Monatschr. f. Geburtsh. u. Gyniik., 1898, viii, 619. (4) Monatsehr. f. Geburtskunde, xxxi, 289. (5) De Lee: Principles and Practice of Obstetrics. 23
EAST
NINETY-THIRD
(For &se&n
STREET.
seep’. 664.)
IS INTERFERENCE JUSTIFIABLE AFTER TWENTY-FOUR HOURS OF LABOR WHEN NO OTHER INDICATION IS PRESENT 1” A
STUDY
BASED UPON A SERIES OF PROLONGED LABORS CONSERVA~VELY TREATED
BY ALFRED
C. BECK,
M.D., BROOKLYN,
N. Y.
T
HE sense of security which is obtained by the use of the two flap, low incision cesarean section after a test of labor, has led us to resort more frequently to a thorough test of labor whenever relative By this routine we mean one that has disproportion exists. allowed sufficient time for complete dilatation and several hours of second stage pains, as we have learned that accurate conclusions concerning the need for suprapubic delivery can be obtained only after the patient has been permitted to completely dilate her cervix and have several hours of second stage pains with ruptured membranes. While the majority of the patients so treated have been delivered either spontaneously or by some relatively simple procedure, a number of them have been many hours in labor. The end results in these instances of prolonged labor were so satisfactory that we were led to question the value of many of the procedures which have been advised as a prophylaxis against prolonged and difficult labor. In order that we might test out this hypothesis we decided to abandon these measures and accordingly conducted a series of cases in which we paid no attention to the size of the child or the so-called danger of allowing the pregnancy to continue beyond the expected, date of Occipitoposteriors were managed expectantly and no confinement. *Read at the Forty-seventh ington, D. C., May l-3, 1922.
Annual
Meeting
of the
American
Gynecological
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Wash.