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Mesenteric vascular occlusion in late pregnancy
COMMUNICATIONS IN BRIEF
Mesenteric vascular late pregnancy J.
BRUCE
COX,
occlusion
in
a trace of glucose in a routine urine sample. At 34 weeks of gestation a routine urinalysis revealed the presence of a three plus glucose and a glucose tolerance test was planned for the postpartum period. The weight gain had been 10 Kg. At 35 weeks’ gestation, suddenly at midnight the patient began having intermittent abdominal pain with associated nausea and backache. Physical examination was essentially normal. The uterus was well relaxed and the fetal heart tones were normal and regular. Tenderness was present over the symphysis and the groins. A catheterized specimen of urine contained many white blood cells. The patient vomited for the first time during the examination. She was admitted to the hospital for the investigation of the pyuria and unexplained abdominal pain. Intravenous fluid was administered and she was given nothing by mouth. Four hours later the pain was localized to the left side of the uterus; the temperature was normal, the blood pressure was slightly elevated; and the pulse which had been 72 was now 120 per minute. Four hours later the uterus became tense and intermittent contractions occurred. White blood cell count was 20,000. The pain in the abdomen became more marked and the fetal heart tones became elevated to 20@ per minute. A vaginal examination with sterile precaution revealed the cervix to be 3 cm. dilated but thick. A tentative diagnosis of partial abruptio placentae was made and it was decided that immediate cesarean section was indicated. Under general anesthesia a laparotrachelotomy was done. Upon entering the peritoneal cavity, a moderate amount of serosanguineous fluid was observed. However, the significance of this finding was not realized at the time. A living 2,550 gram female infant was delivered which required 4 minutes of endotracheal resuscitation before adequate respiration and crying were established. Upon inspection of the placenta prior to removal it was found no abruptio had occurred. Following closure of the uterus, inspection of the adnexa and appendix revealed no acute pathologic lesion. It was at this time that an area of gangrenous small bowel was visualized, measuring approximately 9 inches in length and occurring 15 inches proximal to the ileocecal valve. The section of bowel was deep purple in color, edematous, and exuding the serosanguineous fluid previously mentioned. There were no adhesions, volvulus, or intussusception. Excision of the gangrenous bowel and endto-end anastomosis was then performed. Following this the patient had a rapid recovery
M.D.
Department of Obstetrics and Gynecology, University of Chicago School of Medicine, the Chicago Lying-in Hospital, Chicago,
the and Illi-
nOiS
M
E s E N T E R I c thrombosis creates a difficult diagnostic problem at any time, but this difficulty is markedly increased in the presence of pregnancy and, especially, in late pregnancy. In treatment for this complication the shock process must be combated, circulating fluid volumes must be restored, antibiotics administered, decompression of the gastrointestinal tract carried out and early operation performed. Definitive treatment is excision of the necrotic bowel no matter how large or small a segment this is. General surgical principles will then decide whether an end-to-end anastomosis, end-to-side anastomosis, or an ileoileostomy would be the procedure of choice. One author has advised the use of anticoagulants postoperatively*; however, in the presence of pregnancy the use of bishydroxycoumarin would be definitely contraindicated and heparin, alone, would have to be used. In the presence of pregnancy the complications of the procedure are worsened by the possibility of spontaneous abortion, premature labor, and difllculty in mechanically performing the operation with the enlarged uterus. The following case demonstrates some of these findings and the problems involved.
Mrs. C. D. was first seen in the Prenatal Clinic on April 26, 1961. She was a 19-year-old, white, married gravida i, para 0, with typical signs of early pregnancy. It should be noted that the patient had no history of previous abdominal surgery. Physical examination revealed a somewhat obese girl with completely normal findings other than the presence of a 6 weeks intrauterine pregnancy. The prenatal course was completely uneventful until 32 weeks’ gestation when she exhibited
128
Volume Number
88 1
Communications
in brief
129
Fig. 1. Area of infarction showing destruction of mucosa and hemorrhage into muscularis. Marked leukocytic infiltration of blood vessels. and normal gastrointestinal function returned in a few days. The infant, unfortunately, died after 14 hours of respiratory distress syndrome. Autopsy of the newborn revealed only multiple petechial hemorrhages of the lungs. A glucose tolerance test done during the recovery of the mother revealed a frankly diabetic curve. Since then the caSe has been well controlled by dietary means, alone, and has required no insulin. Pathologic sections from the gangrenous bowel revealed marked changes in many blood vessels. They were described as being far more marked than would be expected simply as a result of the infarction. There were numerous polymorphonuclear leukocytes in the walls as well as in the lumen and the adventitia. Masses of fibrin were also deposited in many of the vessels. All layers of muscle and the mucosa were heavily infiltrated by blood and were partially destroyed. The pathologists consulted could not make a specific diagnosis from the sections studied.
In retrospect this cast exhibited many of the features typical of this condition: leukocytosis, abdominal pain, relative lack of physical findings, and, most particularly, the finding of the serosanguineous fluid in the peritoneal cavity, which is diagnostic in this venous-type occlusion. The sudden occurrence of intrauterine distress, associated with marked increased tonicity of the uterus which led to our mistaken diagnosis of abruptio placentae is somewhat difficult to explain. However, the presence of the large amount of irritating fluid in the abdomen may have triggered the contractions of the uterus. Absorption of this fluid may also have caused the intrauterine distress and this, coupled with the maternal diabetes, prematurity, and the delivery by cesarean section set the stage for the respiratory dis-
130
Communications
in brief
tress syndrome (hyaline membrane disease] which caused the infant’s death. The significance of diabetes mellitus in this case is rather difficult to evaluate. Neither the American literature nor the European literature describes any significant correlation between diabetes and mesenteric vascular occlusion. The venous vasculitis described in the pathologic specimen here is, of course, not specific for diabetes. However, a case such as this does tend to emphasize the increased rate of complications inherent in diabetic pregnancy. Any significant glucosuria in pregnancy should not go uninvestigated. In this case, obviously undiagnosed, it became manifest in late pregnancy when insulin demands became greatest. Therefore, although rare, the syndrome of acute mesenteric vascular occlusion must be considered in cases of acute abdominal pain in pregnancy, either early or late. Thr diagnosis is especially difficult to make in late pregnancy but because of the poor prognosis exploratory laporatomy is not always indicated. REFERENCES
1. Krikal, 2. Luke,
Z.: Gynecologia 149: 162, Josephus C.: Lancet 1: 552,
The Louelace 4800 Gibson Albuquerque,
Blvd., New
Extraperitoneal internal iliac uterus-saving uncontrollable hemorrhage
S.E. Mexico
ligation of the arteries as a life- and procedure for postpartum
SHINRYO
SHINAGAWA,
Department Faculty Hirosaki,
of of
1960. 1943.
Obstetrics and Medicine, Hirosaki
M.D. Gynecology, University,
Japan
The author has observed a normal pregnancy and successful delivery 7 months after ligation of the internal iliac arteries for uncontrollable postpartum hemorrhage in a previous pregnancy. A 31-year-old woman, gravida ii, para ii, was admitted to the author’s clinic on Dec. 30, 1961, at 6:00 A.M., because of labor pains of 4 hours’ duration. At 8:28 A.M. a female baby weighing 3,770 grams was delivered without difficulty. The placenta was delivered at 8:35 A.M. spontaneously. Following the delivery of the baby, however, profuse bleeding per vaginam started and the placental delivery did not decrease the degree of bleeding
at all, despite the fact that contractions of literus were normal. Examination disclosed a deep lacrration of approximately 10 cm. in diameter at the I o’clock site of the cervix. Immediately sutures were placed, but the hemorrhage still was not controlled and the general condition of the patient was unfavorable. No coagulation defect was detected. Administration of oxytocic substances and other ordinary measures were tried without benefit. Meantime, oxygen inhalation and 1,800 C.C. of whole blood were given. The estimated total blood loss was approximately 2,500 C.C. As final hemostatic means ligation of the internal iliac arteries was performed. Because of the patient’s serious general condition an extraperitoneal approach by a single midline longitudinal incision1 was chosen. Immediately after ligation of the arteries the bleeding stopped. The postoperative course was uneventful and on the twenty-third postoperative day the patient was dismissed from hospital. On dismissal from hospital the author told her that there was still a possibility of further pregnancy although he had no knowledge of such a report in medical literature. Seven months later he was able to confirm his opinion. On Aug. 18, 1962, the patient visited the clinic because of amenorrhea of 6 weeks’ duration. The last menstrual period was July 1, 1962. Vaginal examination revealed signs of pregnancy and this was confirmed by a positive Mainini reaction. The prenatal course was uneventful. On April 10, 1963, at the forty-first week of pregnancy, before the onset of labor pains, a transperitoneal cesarean section was performed because cervical dystocia due to the cicatrical rigidity of the cervix was expected. A female fetus weighing 3,350 grams was delivered without difficulty. Before the closure of abdominal wall, the parametrial extraperitoneal space was opened in the right side and it was confirmed that the internal iliac artery had in fact been obliterated. After an uneventful postoperative course of 12 days, she and the baby left hospital well, From the experience obtained in this case it seems that: 1. Hysterectomy is not necessarily always indicated in uncontrollable obstetric and gynecologic hemorrhages, especially when the hemorrhage is originating from the cervix or from the lower uterine segment. On many occasions hemostasis is well accomplished by ligation of the internal iliac or uterine arteries. 2. Pregnancy is still possible in patients with ligated internal iliac arteries. With this procedure, however, the ovarian arteries should not be ligated in order to protect the ovarian functions. 3. The extraperitoneal approach is the procedure of choice for ligation of the internal iliac arteries, at least in patients with serious general condition or when emergency operation is re-
Mesenteric vascular late pregnancy J.
BRUCE
COX,
occlusion
in
a trace of glucose in a routine urine sample. At 34 weeks of gestation a routine urinalysis revealed the presence of a three plus glucose and a glucose tolerance test was planned for the postpartum period. The weight gain had been 10 Kg. At 35 weeks’ gestation, suddenly at midnight the patient began having intermittent abdominal pain with associated nausea and backache. Physical examination was essentially normal. The uterus was well relaxed and the fetal heart tones were normal and regular. Tenderness was present over the symphysis and the groins. A catheterized specimen of urine contained many white blood cells. The patient vomited for the first time during the examination. She was admitted to the hospital for the investigation of the pyuria and unexplained abdominal pain. Intravenous fluid was administered and she was given nothing by mouth. Four hours later the pain was localized to the left side of the uterus; the temperature was normal, the blood pressure was slightly elevated; and the pulse which had been 72 was now 120 per minute. Four hours later the uterus became tense and intermittent contractions occurred. White blood cell count was 20,000. The pain in the abdomen became more marked and the fetal heart tones became elevated to 20@ per minute. A vaginal examination with sterile precaution revealed the cervix to be 3 cm. dilated but thick. A tentative diagnosis of partial abruptio placentae was made and it was decided that immediate cesarean section was indicated. Under general anesthesia a laparotrachelotomy was done. Upon entering the peritoneal cavity, a moderate amount of serosanguineous fluid was observed. However, the significance of this finding was not realized at the time. A living 2,550 gram female infant was delivered which required 4 minutes of endotracheal resuscitation before adequate respiration and crying were established. Upon inspection of the placenta prior to removal it was found no abruptio had occurred. Following closure of the uterus, inspection of the adnexa and appendix revealed no acute pathologic lesion. It was at this time that an area of gangrenous small bowel was visualized, measuring approximately 9 inches in length and occurring 15 inches proximal to the ileocecal valve. The section of bowel was deep purple in color, edematous, and exuding the serosanguineous fluid previously mentioned. There were no adhesions, volvulus, or intussusception. Excision of the gangrenous bowel and endto-end anastomosis was then performed. Following this the patient had a rapid recovery
M.D.
Department of Obstetrics and Gynecology, University of Chicago School of Medicine, the Chicago Lying-in Hospital, Chicago,
the and Illi-
nOiS
M
E s E N T E R I c thrombosis creates a difficult diagnostic problem at any time, but this difficulty is markedly increased in the presence of pregnancy and, especially, in late pregnancy. In treatment for this complication the shock process must be combated, circulating fluid volumes must be restored, antibiotics administered, decompression of the gastrointestinal tract carried out and early operation performed. Definitive treatment is excision of the necrotic bowel no matter how large or small a segment this is. General surgical principles will then decide whether an end-to-end anastomosis, end-to-side anastomosis, or an ileoileostomy would be the procedure of choice. One author has advised the use of anticoagulants postoperatively*; however, in the presence of pregnancy the use of bishydroxycoumarin would be definitely contraindicated and heparin, alone, would have to be used. In the presence of pregnancy the complications of the procedure are worsened by the possibility of spontaneous abortion, premature labor, and difllculty in mechanically performing the operation with the enlarged uterus. The following case demonstrates some of these findings and the problems involved.
Mrs. C. D. was first seen in the Prenatal Clinic on April 26, 1961. She was a 19-year-old, white, married gravida i, para 0, with typical signs of early pregnancy. It should be noted that the patient had no history of previous abdominal surgery. Physical examination revealed a somewhat obese girl with completely normal findings other than the presence of a 6 weeks intrauterine pregnancy. The prenatal course was completely uneventful until 32 weeks’ gestation when she exhibited
128
Volume Number
88 1
Communications
in brief
129
Fig. 1. Area of infarction showing destruction of mucosa and hemorrhage into muscularis. Marked leukocytic infiltration of blood vessels. and normal gastrointestinal function returned in a few days. The infant, unfortunately, died after 14 hours of respiratory distress syndrome. Autopsy of the newborn revealed only multiple petechial hemorrhages of the lungs. A glucose tolerance test done during the recovery of the mother revealed a frankly diabetic curve. Since then the caSe has been well controlled by dietary means, alone, and has required no insulin. Pathologic sections from the gangrenous bowel revealed marked changes in many blood vessels. They were described as being far more marked than would be expected simply as a result of the infarction. There were numerous polymorphonuclear leukocytes in the walls as well as in the lumen and the adventitia. Masses of fibrin were also deposited in many of the vessels. All layers of muscle and the mucosa were heavily infiltrated by blood and were partially destroyed. The pathologists consulted could not make a specific diagnosis from the sections studied.
In retrospect this cast exhibited many of the features typical of this condition: leukocytosis, abdominal pain, relative lack of physical findings, and, most particularly, the finding of the serosanguineous fluid in the peritoneal cavity, which is diagnostic in this venous-type occlusion. The sudden occurrence of intrauterine distress, associated with marked increased tonicity of the uterus which led to our mistaken diagnosis of abruptio placentae is somewhat difficult to explain. However, the presence of the large amount of irritating fluid in the abdomen may have triggered the contractions of the uterus. Absorption of this fluid may also have caused the intrauterine distress and this, coupled with the maternal diabetes, prematurity, and the delivery by cesarean section set the stage for the respiratory dis-
130
Communications
in brief
tress syndrome (hyaline membrane disease] which caused the infant’s death. The significance of diabetes mellitus in this case is rather difficult to evaluate. Neither the American literature nor the European literature describes any significant correlation between diabetes and mesenteric vascular occlusion. The venous vasculitis described in the pathologic specimen here is, of course, not specific for diabetes. However, a case such as this does tend to emphasize the increased rate of complications inherent in diabetic pregnancy. Any significant glucosuria in pregnancy should not go uninvestigated. In this case, obviously undiagnosed, it became manifest in late pregnancy when insulin demands became greatest. Therefore, although rare, the syndrome of acute mesenteric vascular occlusion must be considered in cases of acute abdominal pain in pregnancy, either early or late. Thr diagnosis is especially difficult to make in late pregnancy but because of the poor prognosis exploratory laporatomy is not always indicated. REFERENCES
1. Krikal, 2. Luke,
Z.: Gynecologia 149: 162, Josephus C.: Lancet 1: 552,
The Louelace 4800 Gibson Albuquerque,
Blvd., New
Extraperitoneal internal iliac uterus-saving uncontrollable hemorrhage
S.E. Mexico
ligation of the arteries as a life- and procedure for postpartum
SHINRYO
SHINAGAWA,
Department Faculty Hirosaki,
of of
1960. 1943.
Obstetrics and Medicine, Hirosaki
M.D. Gynecology, University,
Japan
The author has observed a normal pregnancy and successful delivery 7 months after ligation of the internal iliac arteries for uncontrollable postpartum hemorrhage in a previous pregnancy. A 31-year-old woman, gravida ii, para ii, was admitted to the author’s clinic on Dec. 30, 1961, at 6:00 A.M., because of labor pains of 4 hours’ duration. At 8:28 A.M. a female baby weighing 3,770 grams was delivered without difficulty. The placenta was delivered at 8:35 A.M. spontaneously. Following the delivery of the baby, however, profuse bleeding per vaginam started and the placental delivery did not decrease the degree of bleeding
at all, despite the fact that contractions of literus were normal. Examination disclosed a deep lacrration of approximately 10 cm. in diameter at the I o’clock site of the cervix. Immediately sutures were placed, but the hemorrhage still was not controlled and the general condition of the patient was unfavorable. No coagulation defect was detected. Administration of oxytocic substances and other ordinary measures were tried without benefit. Meantime, oxygen inhalation and 1,800 C.C. of whole blood were given. The estimated total blood loss was approximately 2,500 C.C. As final hemostatic means ligation of the internal iliac arteries was performed. Because of the patient’s serious general condition an extraperitoneal approach by a single midline longitudinal incision1 was chosen. Immediately after ligation of the arteries the bleeding stopped. The postoperative course was uneventful and on the twenty-third postoperative day the patient was dismissed from hospital. On dismissal from hospital the author told her that there was still a possibility of further pregnancy although he had no knowledge of such a report in medical literature. Seven months later he was able to confirm his opinion. On Aug. 18, 1962, the patient visited the clinic because of amenorrhea of 6 weeks’ duration. The last menstrual period was July 1, 1962. Vaginal examination revealed signs of pregnancy and this was confirmed by a positive Mainini reaction. The prenatal course was uneventful. On April 10, 1963, at the forty-first week of pregnancy, before the onset of labor pains, a transperitoneal cesarean section was performed because cervical dystocia due to the cicatrical rigidity of the cervix was expected. A female fetus weighing 3,350 grams was delivered without difficulty. Before the closure of abdominal wall, the parametrial extraperitoneal space was opened in the right side and it was confirmed that the internal iliac artery had in fact been obliterated. After an uneventful postoperative course of 12 days, she and the baby left hospital well, From the experience obtained in this case it seems that: 1. Hysterectomy is not necessarily always indicated in uncontrollable obstetric and gynecologic hemorrhages, especially when the hemorrhage is originating from the cervix or from the lower uterine segment. On many occasions hemostasis is well accomplished by ligation of the internal iliac or uterine arteries. 2. Pregnancy is still possible in patients with ligated internal iliac arteries. With this procedure, however, the ovarian arteries should not be ligated in order to protect the ovarian functions. 3. The extraperitoneal approach is the procedure of choice for ligation of the internal iliac arteries, at least in patients with serious general condition or when emergency operation is re-