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Intravenous pituitary extract in the low cervical cesarean section
441)
Al'vrERH'AX ,fOVlU\AL IW OHMTl']'I'I{ICK AND HYNEI'OJ,()(~\'
exceed four and one·lmlf hours whid1 ix lh<' avcmgH duration of this ant•r:Jtor'H ll'ft haJJrl eannot he UHvd n·ry satisfactorily ak a guide on that sidt;, a st>r·ond or furtlwr injections may lw m:1de without :my in judous effects. Morphine sulplmte may !Je U!!ed to l't
INTRAVENOUS PI'rUITAH.Y EX't'RAC'l' JN 'I'HI
HoY
,J.
11EPFERNA~,
.M.D.. l<'.A.C.S .. BosToN, MARS.
(Visitimg Obstetricill!n amd 0-ynecologist, Carney JltMpital)
IRM, immediate contractiun of the uterus after the extraetiou of the baby, is a distinct advantage when performing laparotrachelotomy. If the uterus remain;,; flaccid and boggy, fn:'£' bleeding: occur;; from the incisicn, obscuring· the GlWrative field :mrl depl€'tiug the patient. Repeated massage of the fundus is necesHary, a time-consuming, troublesome proced LU't'.
F
1\ poorly contracting uterus frt'l[l!f'lltly ~~awws somt difficulty in the delivery of the secudines and nut rarely th(• hand must he introdnePd into the uterine cavity to separah' and l'f'lllOYt' tl1e placPnta or nwmbranes. The action of thl' uterns d uriug t lw (;peration dPtf'rtnines to a largE' degree, the type of convalescenec A flabby fundm; with excessiH bleeding prolong·:; the operating time, inci·eases tfw amount of anesthesia and predisposes to shock postpartum hemorrhage, vomiting and distention. It also induces diminished resistanc<.> to infection. J.Jactation is usually interfered "With and a pet·iod of semi-invalidism of weeks or even months may follow. On the other hand, a nteru:> which shuts 1.lowu firmly as soon as the fetus is deliverrd, permits rapid sntnring with a minimum of handling and tissue trauma and a bkod lo~s which is negligible. The postoperative period is wmally ~:mooth and uncomplicated, with very little vomiting and di~1tEntion. ~Jxcept foe the abdominal incision, these patients, as a rule, have a puerperium comparable to that following a normal pelvic delivery. The latter conditions seem to follow more frequently wl:w.ta pituitary extract. is administered by vein.
HEFFERNAN:
IN'l'RAVENOUS PITUI'l'ARY EX'rRAC'l'
447
DOSAGE AND TIME OF ADMINISTRATION
Pituitary extract, 0.5 c.c. diluted with 3 c.c. warm normal salt solution is injected slowly into a vein in the elbow. The bladder having been stripped off the lower uterine segment, the latter is incised transversely with a knife, dovvn to the membranes. As soon as this incision is started, the intravenous injection is begun. This allows the operator sufficient time to complete the incision ('vith bandage scissorsPhaneuf technic), rupture the membranes and slip the left hand under the baby's head. This hand maintains cephalic flexion and acts as a shoehorn so that the now firmly contracting uterus, occasionally aided by pressure on the upper abdomen, forces the head through the uterine incision. Instruments to rotate or extract the head are entirely unnecessary when this technic is employed. Gynergen one ampule i;;; given intramuscularly after pituitary extract. At first 1 c.c. of pitl1itary extract was used. In some cases bradycardia and cyanosis resulted, so that this dose was considered to be excessive. No harmful effects have been observed since the dosage has been reduced. RESUME OF' 100 CASES One hundred transverse cervical cesarean sections, with intravenous administration of pituitary extract, were performed on 84 patients. Two women in the series were sectioned 3 times and 5 had 2 cesarean sections. These were done for the following indications: Cephalopelvic disproportion Eclampsia Other toxemias Placenta previa Cervical stenosis Cardiae disease Previous cesarean section Previous myomectomy (during pregnancy) Obstructing fibroid (Porro) Abruptio placentae (Porro) Complete perineal repair
59 2
14 6
2 3
9
2 1 1 1
100
In patients with a marked hypertension, pitocin was employed. The intravenous stimulation was a tremendous help in the placenta previa eases, in whom troublesome bleeding frequently occurred before the intravenous technic was adopted. Ether Spinal anesthesia Loeal anesthesia
ANESTHESIA
77
6
17
100
Spinal anesthesia was used principally when pu]monary complications were present. Local anesthesia, with preliminary medication
448
AMERICAN ,JOURNAL OF' OBSTF:TRICB ,\XD nYXEI'OLOOY
with tlH• harbi1 llt'tltes, wa:-> Pmplo,\ t•d in t lu· to X<>Hl it·, nrphriti1· lower nterinP srg·mpnt eannot lw l'ntiJ•<•ly (•ontr~:IIPd by lo<•;.Jl am•sthesia. 'l'hr utr>ms t'ontracts so llllH'll better·, wlwn lo<·al m· :-.pillal an<•sthe;.;ia ii'i employed, that thr adnmtlq.res of intnn<'lWl!s pitnita1·y nwdication art' fm· greatrr wlH•n ether i, HKP
Hl
7
3
100 Tlw :failures w<•n•: ( l) Para h, prPt•damptk toxemiu, abruptio plan•lltrte. 110 lal1or, with hemonhagie infiltration of myomrtrium, preventing utt>rine rontraetion. hysterectomy. (:! J Pam ii, aged thirty-Jin:, myonwctomy M three• and one-half months. Lower 11terine segment Pxtremely vuseular. Con~idernble hemorrhagt', n•peated massagP lllHl twfl ntra dost•s pituitary extrac-t nN·(·s~m·y.
Thert> WfTf' no matt>rmll deaths, no stillbirths nnd three neonatal deaths in the st'rit>s. Therf' WN'!.' no cases of postpartum hemnrrha!!<'. Although I haH not y(•t had oeeasic:n to nse it for that purpo:'>e. tlw exeellent results ohstTVf'd in tiH' above series would serm to indicat<• that intravenous pituitary t•xtract wonld :-:peedily eontl'ol a postpartum hemGrrhage which would not resp
IIYDROP:S 'l'UBAI
T. ·wALKER, JI.A .. lVI.D., MARE Isr.AND,
CAUI?.
G RA VEH,1 of all tlw authors writing
011 gynecologieal ~ubjettH seem,; to ~tand alone in stressing the important•e ant1 devastating sequelae of appendiceal episodes in young girk All too ofteu vague pains in the abdomen whieh are nol followed by the textbook syndrome of nausPa aml vomiting with rigidity, peri· toneal refl(•x, etc., arc dismissed, parti~ularly in young girls approaching the menarche, as symptom~ of beginning m<·nstrual funr.tion and are considered of no great significance. That such a de>v i~ <'rroncous and if followeil as a routin•· in practice will occasionally result in disaster for some youngster is the motive which compels me to r~>port the :following ease. It will serve as an example of the grave consequen<"'s which may follow a neglected appendicitis in young girls.
*From the Gynecologieal Service, Outpatient D<:partment. l'. S. Naval HospitaL
Al'vrERH'AX ,fOVlU\AL IW OHMTl']'I'I{ICK AND HYNEI'OJ,()(~\'
exceed four and one·lmlf hours whid1 ix lh<' avcmgH duration of this ant•r:Jtor'H ll'ft haJJrl eannot he UHvd n·ry satisfactorily ak a guide on that sidt;, a st>r·ond or furtlwr injections may lw m:1de without :my in judous effects. Morphine sulplmte may !Je U!!ed to l't
INTRAVENOUS PI'rUITAH.Y EX't'RAC'l' JN 'I'HI
HoY
,J.
11EPFERNA~,
.M.D.. l<'.A.C.S .. BosToN, MARS.
(Visitimg Obstetricill!n amd 0-ynecologist, Carney JltMpital)
IRM, immediate contractiun of the uterus after the extraetiou of the baby, is a distinct advantage when performing laparotrachelotomy. If the uterus remain;,; flaccid and boggy, fn:'£' bleeding: occur;; from the incisicn, obscuring· the GlWrative field :mrl depl€'tiug the patient. Repeated massage of the fundus is necesHary, a time-consuming, troublesome proced LU't'.
F
1\ poorly contracting uterus frt'l[l!f'lltly ~~awws somt difficulty in the delivery of the secudines and nut rarely th(• hand must he introdnePd into the uterine cavity to separah' and l'f'lllOYt' tl1e placPnta or nwmbranes. The action of thl' uterns d uriug t lw (;peration dPtf'rtnines to a largE' degree, the type of convalescenec A flabby fundm; with excessiH bleeding prolong·:; the operating time, inci·eases tfw amount of anesthesia and predisposes to shock postpartum hemorrhage, vomiting and distention. It also induces diminished resistanc<.> to infection. J.Jactation is usually interfered "With and a pet·iod of semi-invalidism of weeks or even months may follow. On the other hand, a nteru:> which shuts 1.lowu firmly as soon as the fetus is deliverrd, permits rapid sntnring with a minimum of handling and tissue trauma and a bkod lo~s which is negligible. The postoperative period is wmally ~:mooth and uncomplicated, with very little vomiting and di~1tEntion. ~Jxcept foe the abdominal incision, these patients, as a rule, have a puerperium comparable to that following a normal pelvic delivery. The latter conditions seem to follow more frequently wl:w.ta pituitary extract. is administered by vein.
HEFFERNAN:
IN'l'RAVENOUS PITUI'l'ARY EX'rRAC'l'
447
DOSAGE AND TIME OF ADMINISTRATION
Pituitary extract, 0.5 c.c. diluted with 3 c.c. warm normal salt solution is injected slowly into a vein in the elbow. The bladder having been stripped off the lower uterine segment, the latter is incised transversely with a knife, dovvn to the membranes. As soon as this incision is started, the intravenous injection is begun. This allows the operator sufficient time to complete the incision ('vith bandage scissorsPhaneuf technic), rupture the membranes and slip the left hand under the baby's head. This hand maintains cephalic flexion and acts as a shoehorn so that the now firmly contracting uterus, occasionally aided by pressure on the upper abdomen, forces the head through the uterine incision. Instruments to rotate or extract the head are entirely unnecessary when this technic is employed. Gynergen one ampule i;;; given intramuscularly after pituitary extract. At first 1 c.c. of pitl1itary extract was used. In some cases bradycardia and cyanosis resulted, so that this dose was considered to be excessive. No harmful effects have been observed since the dosage has been reduced. RESUME OF' 100 CASES One hundred transverse cervical cesarean sections, with intravenous administration of pituitary extract, were performed on 84 patients. Two women in the series were sectioned 3 times and 5 had 2 cesarean sections. These were done for the following indications: Cephalopelvic disproportion Eclampsia Other toxemias Placenta previa Cervical stenosis Cardiae disease Previous cesarean section Previous myomectomy (during pregnancy) Obstructing fibroid (Porro) Abruptio placentae (Porro) Complete perineal repair
59 2
14 6
2 3
9
2 1 1 1
100
In patients with a marked hypertension, pitocin was employed. The intravenous stimulation was a tremendous help in the placenta previa eases, in whom troublesome bleeding frequently occurred before the intravenous technic was adopted. Ether Spinal anesthesia Loeal anesthesia
ANESTHESIA
77
6
17
100
Spinal anesthesia was used principally when pu]monary complications were present. Local anesthesia, with preliminary medication
448
AMERICAN ,JOURNAL OF' OBSTF:TRICB ,\XD nYXEI'OLOOY
with tlH• harbi1 llt'tltes, wa:-> Pmplo,\ t•d in t lu· to X<>Hl it·, nrphriti1·
Hl
7
3
100 Tlw :failures w<•n•: ( l) Para h, prPt•damptk toxemiu, abruptio plan•lltrte. 110 lal1or, with hemonhagie infiltration of myomrtrium, preventing utt>rine rontraetion. hysterectomy. (:! J Pam ii, aged thirty-Jin:, myonwctomy M three• and one-half months. Lower 11terine segment Pxtremely vuseular. Con~idernble hemorrhagt', n•peated massagP lllHl twfl ntra dost•s pituitary extrac-t nN·(·s~m·y.
Thert> WfTf' no matt>rmll deaths, no stillbirths nnd three neonatal deaths in the st'rit>s. Therf' WN'!.' no cases of postpartum hemnrrha!!<'. Although I haH not y(•t had oeeasic:n to nse it for that purpo:'>e. tlw exeellent results ohstTVf'd in tiH' above series would serm to indicat<• that intravenous pituitary t•xtract wonld :-:peedily eontl'ol a postpartum hemGrrhage which would not resp
IIYDROP:S 'l'UBAI
T. ·wALKER, JI.A .. lVI.D., MARE Isr.AND,
CAUI?.
G RA VEH,1 of all tlw authors writing
011 gynecologieal ~ubjettH seem,; to ~tand alone in stressing the important•e ant1 devastating sequelae of appendiceal episodes in young girk All too ofteu vague pains in the abdomen whieh are nol followed by the textbook syndrome of nausPa aml vomiting with rigidity, peri· toneal refl(•x, etc., arc dismissed, parti~ularly in young girls approaching the menarche, as symptom~ of beginning m<·nstrual funr.tion and are considered of no great significance. That such a de>v i~ <'rroncous and if followeil as a routin•· in practice will occasionally result in disaster for some youngster is the motive which compels me to r~>port the :following ease. It will serve as an example of the grave consequen<"'s which may follow a neglected appendicitis in young girls.
*From the Gynecologieal Service, Outpatient D<:partment. l'. S. Naval HospitaL