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Labor complicated by uterine fibroids and placenta previa
LABOR
COMPLICATED BY UTERINE PLACEHTA PRWIA tJii~~~:~ CHADWICK,
M.D.,*
BOSTON,
FIBROIDS
AND
MASS.
RS. M. M. came to me on May 12, 1.875. She was 42 years of age, had been R widow for two years. A tumor had been diagnosticated 5 yea.rs previously. Menstruation had been escessive and metrorrhagiae frequent. The growth at the navel was 341, inches, and tnidway between the navel and the pubes was X3)$ inches. Palpation showed that the abclomen was the seat of a large tumor. The vagina was unduly moist, and its roof less yielding than usual. The diagnosis of uterine fibroids seemed unequivocal. 1 told the patient to call again in a week, when I could begin treat,ment by subcuta.neous injection of ergotine. ( )II May 17. I had the syringe charged, when something led me to examine t,hr abdomen again with ca.re. Flatness extended over the greater part of the left side of the abdomen. Nodules could be felt only by deep pressure. Fluid alone could produce the flatness. Pregnancy flashed into my mind as the only condition tha,t could explain the phenomenon satisfactorily, and this suspicion t,he stethoscope confirmed by the discovery of the fetal heart sounds two inches below the umbilicus. Tt is neeclless to add that the nodules in the left side were the feet,. A hemorrhage within two weeks caused me to suspect the presence of a placenta previa as a further complication. Further questioning elicited the facts that coitus had taken place but t,hree times since her husband’s death. Sterility during thirteen years of ma.rried life, and the Felief that her age-42 years-fully accounted for the derangement of menstruation, had preventecl any suspicion of the real fact having entered the mind of the patient. On learning the truth, she fell into a state of utter despondency, which persisted to the end, and exercised a very appreciable influence in determining the results. Mrs. M. passed to the full term of pregnancy wit.hout other untowartl tlrents than several smart, hemorrhages, requiring only repose in bed for their arrest. On August 13, the uterus began to contract feebly, but with some regularity. Hemorrhage set in, and soon assumecl alarming proportions; it was checked by plugging the vagina with a Barnes’ dilator. After consulta,tion with Drs. A. D. Sinclair and IS. CT. Cutler, of Boston. &her was administered, and the eeryis gradually dilated by digital pressure a.ntl manipulation. The placenta was previa, but luckily only its border covover a large fibroid, cretl the OS. Tt was found to have its seat immediately in the posterior uterine wall, that descended to the internal OS, and proved a serious obstacle to the insertion of the hand. This was, however, at last, effected, the feet. seized and dragged down. The greatest traction that I dared *Presentc~i
by
John
Rock,
M.D..
Roston.
Mass. 722
LABOR
WITH
UTERINE
FIBROIDS
AND
PLACENTA
PREVIA
723
apply only brought the knees to the vulva. With the exercise of great care, yet considerable force, I insinuated a hand along the curve of the sacrum, between the abdomen of the child and the fibroid tumor; with great difficulty grasped one arm after another, and brought them into the vagina, fracturing the right clavicle during the process. By continuous forcible traction the shoulders were finally delivered, though the head evidently remained above the brim of the pelvis. Again and again I tugged upon the body, while Dr. Sinclair pressed the head clown from above the pubes. At length it descencled suddenly into the pelvis and was at once delivered. The child was asphyxiated hut revived after fifteen minutes, during which artifinial respiration was kept up. He weighed ten pounds. The placenta not coming away, and there being no expulsive efforts of the uterus, the former was removed in a somewhat torn condition by the hand. In order to make sure that no portion had been left, I introduced hy hand into the vagina, and to my dismay felt it pass into the peritoneal cavity outside of the ut.erus. Above the fundus of the uterus could be felt the intestines, but they showed no t.endency to descend into the pelvis. A careful examination of the rent by Dr. Sinclair and myself made evident that it was a transverse tear of the vagina, three or more inches in length, situated just below the insertion of the vagina into the posterior lip of the uterus. Just above this lip, it will be remembered, was the large fibroid which had obstructed clelivery. There seemed to be no hemorrhage, so the ether was removed, the woman turned upon her back, and a tight bandage applied, by which means it was hoped t,hat the edges of the wound would be kept in apposition, owing to the pressure of the uterus. It is useless t,o give the subsequent history in detail. The first day was passed in perfect comfort; on the second, symptoms of peritonitis began to On the third clay, the abdominal distention was so great as to require appear. puncture of the intestines to allow the escape of flatus. Through the same troear, I essayed the injection of nutrient and stimulant fluids into the intestinal canal. The feasibility and objects of this procedure were fully set forth in a paper which I read before the New York Obstetrical Society on November 2, 1875. On the fourth day, septicemia and delirium set in, terminating fatally on the fifth clay. No autopsy could be obtained. Several points in this case seem to merit consideration. I saw one year ago a similar case. Mrs. F. M., 33 years of age, had been married fifteen years without having had children or miscarriages. Menstruation had always been regular until seven months previously ; since then, it had not been seen. After two months of amenorrhea, one of the most eminent and trustworthy physicians of Boston noted nothing abnormal, except that the cervix was almost exciting a fear of commencing cancer. “haid, red Hand granular,”
CHADWICK
(ROCK)
Am.
J. Obst. & Gyncc. October. 1951
Four months later, one of our most prominent ovariotomists, finding several large abdominal tumors, gave an unfavorable prognosis. One month later, the seventh without menstruation, it required no great acumen on our part to recognize advanced pregnancy, complicated by a fibroid tumor larger than a. man’s fist in the anterior uterine wall. At term, the patient was delivered safely by Dr. Kingsbury; at the end of another month, I was unable to find any t.race of the fibroid. I have been able to collect only seven additional instances of labor complicated with uterine fibroids and placenta previa. They are given in detail in the version of my discourse submitted for publication in the Transactions of this Society. The problem naturally presents itself: what course should be pursued when a fibroid tumor is recognized in the pelvis, and likely to interfere with delivery? If seen early enough in the pregnancy, the induction of miscarriage or premature labor would probably be attended by less risk than any other course. Jf the pregna.ncy be too far advanced to allow a reasonable chance of the passage of t,he fetus past the obstruction, then version, and reduction of the size of the head by the trephine, or the cephalotribe, would commend itself to my judgment. I would not perform cesarean section unless the obstructing tumor almost filled the pelvis. The same rules should govern practice, as in obstruction of the pelvis from other causes, except that enucleation of the tumor might in rare instances be feasible in spite of its manifest dangers.
Discussion of Dr. Chadwick’s Mr.
President,,
Fellows
Paper by Dr. A. J. C. Skene*
and Guests:
1My esteemed colleague from Boston, for whom Mine is a most difficult assignment,. I have the utmost personal admiration, has given us the harrowing details of a first pregnancy in a 42.year-old widow who died of septicemia after a most difficult confinement. It was my privilege t,o read the entire manuscript with its many comparable case records. The essayist’s erudition is indicated by the fact that these case reports were gleaned from t,he world of literature, English, German, French, and Austrian. Mr. President, if I interpret the objectives of this newborn Society correctly, it then behooves me to subject this report to critical analysis rather than to indulge in fulsome praise and commiseration. Dr. Chadwick reached his diagnosis in its entirety on May 17 of last year, the pregnancy thtan being of 6 months’ duration, complicated by a blocking fibroid and a suspect placenta previa. In a thoughtful analysis of the safest treatment for pregnancy of varying duration, complicated by a blocking fibroid, the essayist recommends induction of miscarriage or of premature labor if the patient is seen early enough. This was not done here. Thereafter at term, August 13, the lady entered into desultory labor. During the next 24 hours the patient at one time bled so much that the vagina was plugged with a Barnes colpeurguter. Dilatation of the cervix never passed beyond 1 finger. Eventually accouchempnt fore6 was decided upon and carried out by digital and manual dilatation of the cervix, version and extraction, and manual removal of the previa placenta. The details of this delivery and the unfortunate aftermath have been described in great detail by Dr. Chadwick.
Volume Number
62 4
LABOR
WITH
UTERINE
FIBROIDS
AND
PLACENTA
PREVIA
725
Here again the essayist in his most cxcellcnt analysis urges collapse of the aftercomhead by trcphine or cophalotribe as a lifesaving device for the unfortunate parturient. This was not done. Dr. Chadwick qyotes a somewhat similar case t.reated successfully by cesarean section by Dr. Cazin, in Boulogne in 1874. This was not done. The cause of the avulsion of the posterior vaginal wall from the cervix is discussed in great detail. Two possible explanations of this disaster are offered: (I) the great dif%eulty encountered in insinuating the hand between the fetal abdomen and the posterior wall fibroid in order to reach and deliver the arms; (2) the prolonged and vigorous pull from below and push from above which resulted finally in an abrupt descent of the aftercoming head. I submit that this theorizing is largely academic. The incontrovertible fact remains that the avulsion was due to the exhibition of unusual force. Gentlemen, how well we know the strain upon us when a life or two lives are at stake. I am sure that my friend Dr. Chadwick ‘(Let him who is without sin cast the first stone. ” and all of you will forgive this critical analysis and accept or refute it according to your own lights. It remains only for me to emphasize once again the age-old injunction applicable to all “Non vi, sed arte.” operators: Thank you.
ing
COMPLICATED BY UTERINE PLACEHTA PRWIA tJii~~~:~ CHADWICK,
M.D.,*
BOSTON,
FIBROIDS
AND
MASS.
RS. M. M. came to me on May 12, 1.875. She was 42 years of age, had been R widow for two years. A tumor had been diagnosticated 5 yea.rs previously. Menstruation had been escessive and metrorrhagiae frequent. The growth at the navel was 341, inches, and tnidway between the navel and the pubes was X3)$ inches. Palpation showed that the abclomen was the seat of a large tumor. The vagina was unduly moist, and its roof less yielding than usual. The diagnosis of uterine fibroids seemed unequivocal. 1 told the patient to call again in a week, when I could begin treat,ment by subcuta.neous injection of ergotine. ( )II May 17. I had the syringe charged, when something led me to examine t,hr abdomen again with ca.re. Flatness extended over the greater part of the left side of the abdomen. Nodules could be felt only by deep pressure. Fluid alone could produce the flatness. Pregnancy flashed into my mind as the only condition tha,t could explain the phenomenon satisfactorily, and this suspicion t,he stethoscope confirmed by the discovery of the fetal heart sounds two inches below the umbilicus. Tt is neeclless to add that the nodules in the left side were the feet,. A hemorrhage within two weeks caused me to suspect the presence of a placenta previa as a further complication. Further questioning elicited the facts that coitus had taken place but t,hree times since her husband’s death. Sterility during thirteen years of ma.rried life, and the Felief that her age-42 years-fully accounted for the derangement of menstruation, had preventecl any suspicion of the real fact having entered the mind of the patient. On learning the truth, she fell into a state of utter despondency, which persisted to the end, and exercised a very appreciable influence in determining the results. Mrs. M. passed to the full term of pregnancy wit.hout other untowartl tlrents than several smart, hemorrhages, requiring only repose in bed for their arrest. On August 13, the uterus began to contract feebly, but with some regularity. Hemorrhage set in, and soon assumecl alarming proportions; it was checked by plugging the vagina with a Barnes’ dilator. After consulta,tion with Drs. A. D. Sinclair and IS. CT. Cutler, of Boston. &her was administered, and the eeryis gradually dilated by digital pressure a.ntl manipulation. The placenta was previa, but luckily only its border covover a large fibroid, cretl the OS. Tt was found to have its seat immediately in the posterior uterine wall, that descended to the internal OS, and proved a serious obstacle to the insertion of the hand. This was, however, at last, effected, the feet. seized and dragged down. The greatest traction that I dared *Presentc~i
by
John
Rock,
M.D..
Roston.
Mass. 722
LABOR
WITH
UTERINE
FIBROIDS
AND
PLACENTA
PREVIA
723
apply only brought the knees to the vulva. With the exercise of great care, yet considerable force, I insinuated a hand along the curve of the sacrum, between the abdomen of the child and the fibroid tumor; with great difficulty grasped one arm after another, and brought them into the vagina, fracturing the right clavicle during the process. By continuous forcible traction the shoulders were finally delivered, though the head evidently remained above the brim of the pelvis. Again and again I tugged upon the body, while Dr. Sinclair pressed the head clown from above the pubes. At length it descencled suddenly into the pelvis and was at once delivered. The child was asphyxiated hut revived after fifteen minutes, during which artifinial respiration was kept up. He weighed ten pounds. The placenta not coming away, and there being no expulsive efforts of the uterus, the former was removed in a somewhat torn condition by the hand. In order to make sure that no portion had been left, I introduced hy hand into the vagina, and to my dismay felt it pass into the peritoneal cavity outside of the ut.erus. Above the fundus of the uterus could be felt the intestines, but they showed no t.endency to descend into the pelvis. A careful examination of the rent by Dr. Sinclair and myself made evident that it was a transverse tear of the vagina, three or more inches in length, situated just below the insertion of the vagina into the posterior lip of the uterus. Just above this lip, it will be remembered, was the large fibroid which had obstructed clelivery. There seemed to be no hemorrhage, so the ether was removed, the woman turned upon her back, and a tight bandage applied, by which means it was hoped t,hat the edges of the wound would be kept in apposition, owing to the pressure of the uterus. It is useless t,o give the subsequent history in detail. The first day was passed in perfect comfort; on the second, symptoms of peritonitis began to On the third clay, the abdominal distention was so great as to require appear. puncture of the intestines to allow the escape of flatus. Through the same troear, I essayed the injection of nutrient and stimulant fluids into the intestinal canal. The feasibility and objects of this procedure were fully set forth in a paper which I read before the New York Obstetrical Society on November 2, 1875. On the fourth day, septicemia and delirium set in, terminating fatally on the fifth clay. No autopsy could be obtained. Several points in this case seem to merit consideration. I saw one year ago a similar case. Mrs. F. M., 33 years of age, had been married fifteen years without having had children or miscarriages. Menstruation had always been regular until seven months previously ; since then, it had not been seen. After two months of amenorrhea, one of the most eminent and trustworthy physicians of Boston noted nothing abnormal, except that the cervix was almost exciting a fear of commencing cancer. “haid, red Hand granular,”
CHADWICK
(ROCK)
Am.
J. Obst. & Gyncc. October. 1951
Four months later, one of our most prominent ovariotomists, finding several large abdominal tumors, gave an unfavorable prognosis. One month later, the seventh without menstruation, it required no great acumen on our part to recognize advanced pregnancy, complicated by a fibroid tumor larger than a. man’s fist in the anterior uterine wall. At term, the patient was delivered safely by Dr. Kingsbury; at the end of another month, I was unable to find any t.race of the fibroid. I have been able to collect only seven additional instances of labor complicated with uterine fibroids and placenta previa. They are given in detail in the version of my discourse submitted for publication in the Transactions of this Society. The problem naturally presents itself: what course should be pursued when a fibroid tumor is recognized in the pelvis, and likely to interfere with delivery? If seen early enough in the pregnancy, the induction of miscarriage or premature labor would probably be attended by less risk than any other course. Jf the pregna.ncy be too far advanced to allow a reasonable chance of the passage of t,he fetus past the obstruction, then version, and reduction of the size of the head by the trephine, or the cephalotribe, would commend itself to my judgment. I would not perform cesarean section unless the obstructing tumor almost filled the pelvis. The same rules should govern practice, as in obstruction of the pelvis from other causes, except that enucleation of the tumor might in rare instances be feasible in spite of its manifest dangers.
Discussion of Dr. Chadwick’s Mr.
President,,
Fellows
Paper by Dr. A. J. C. Skene*
and Guests:
1My esteemed colleague from Boston, for whom Mine is a most difficult assignment,. I have the utmost personal admiration, has given us the harrowing details of a first pregnancy in a 42.year-old widow who died of septicemia after a most difficult confinement. It was my privilege t,o read the entire manuscript with its many comparable case records. The essayist’s erudition is indicated by the fact that these case reports were gleaned from t,he world of literature, English, German, French, and Austrian. Mr. President, if I interpret the objectives of this newborn Society correctly, it then behooves me to subject this report to critical analysis rather than to indulge in fulsome praise and commiseration. Dr. Chadwick reached his diagnosis in its entirety on May 17 of last year, the pregnancy thtan being of 6 months’ duration, complicated by a blocking fibroid and a suspect placenta previa. In a thoughtful analysis of the safest treatment for pregnancy of varying duration, complicated by a blocking fibroid, the essayist recommends induction of miscarriage or of premature labor if the patient is seen early enough. This was not done here. Thereafter at term, August 13, the lady entered into desultory labor. During the next 24 hours the patient at one time bled so much that the vagina was plugged with a Barnes colpeurguter. Dilatation of the cervix never passed beyond 1 finger. Eventually accouchempnt fore6 was decided upon and carried out by digital and manual dilatation of the cervix, version and extraction, and manual removal of the previa placenta. The details of this delivery and the unfortunate aftermath have been described in great detail by Dr. Chadwick.
Volume Number
62 4
LABOR
WITH
UTERINE
FIBROIDS
AND
PLACENTA
PREVIA
725
Here again the essayist in his most cxcellcnt analysis urges collapse of the aftercomhead by trcphine or cophalotribe as a lifesaving device for the unfortunate parturient. This was not done. Dr. Chadwick qyotes a somewhat similar case t.reated successfully by cesarean section by Dr. Cazin, in Boulogne in 1874. This was not done. The cause of the avulsion of the posterior vaginal wall from the cervix is discussed in great detail. Two possible explanations of this disaster are offered: (I) the great dif%eulty encountered in insinuating the hand between the fetal abdomen and the posterior wall fibroid in order to reach and deliver the arms; (2) the prolonged and vigorous pull from below and push from above which resulted finally in an abrupt descent of the aftercoming head. I submit that this theorizing is largely academic. The incontrovertible fact remains that the avulsion was due to the exhibition of unusual force. Gentlemen, how well we know the strain upon us when a life or two lives are at stake. I am sure that my friend Dr. Chadwick ‘(Let him who is without sin cast the first stone. ” and all of you will forgive this critical analysis and accept or refute it according to your own lights. It remains only for me to emphasize once again the age-old injunction applicable to all “Non vi, sed arte.” operators: Thank you.
ing