- Email: [email protected]
Multiple spontaneous perforations in a term uterus
Multiple spontaneous perforations
in a term uterus
A case report
WALTER Middletown,
FENING,
M.D.
Ohio
M u L T I P L E spontaneous perforations in a term uterus with resulting hemoperitoneum and shock is a very unusual and dramatic obstetric complication. When the perforations were recognized at the time of laparotomy, a diagnosis of placenta percreta with intraperitoneal hemorrhage was made. Later, the pathologists could not substantiate a diagnosis of placenta percreta, describing them only as traumatic perforations of undetermined nature. Most of the reported cases of perforations are associated with myomectomy or cesarean scars or postcurettage trauma. In this case there is no evidence that any of these factors pertain. The patient was a 23-year-old white woman, gravida iv, para ii. The first 2 pregnancies resulted in full-term normal infants while the third terminated in a questionable abortion at 8 weeks. Curettings showed only endometritis with no evidence of villi or decidua. Questioning of the physician who performed this curettage 2 years before the present pregnancy and study of the hospital chart failed to reveal anything unusual that might indicate that perforation of the uterus had occurred. The present pregnancy had been uneventful up to the morning of admission. The last menstrual period had occurred on Jan. 29, 1958, and the expected date of delivery was Nov. 6, 1959. About 2 A.M. on Nov. 17, 1959, the patient awakened with pain across the upper abdomen which was steady in character and became increasingly severe. She had several episodes of diarrhea but no dysuria or vaginal bleeding. Fetal movements were not felt after the pain becamr
more severe. She was admitted at 6: 10 A.M. to Middletown hospital having mild uterine contractions and a purulent vaginal discharge, according to the admitting nurse. Cervical dilatation was 4 cm. and the fetal heart tones were recorded as questionably present. The admitting blood pressure was 128/94. She continued to have upper abdominal pain but no strong uterine contractions. By 9:30 A.M. the blood pressure was unobtainable. Digitoxin (0.2 mg.) was given intramuscularly. The pulse rate continued to be 145 per minute and the blood pressure was recorded at various instances to be SO/So. When I saw the patient for the first time, about 11: 30 A.M., she was quite pale and dyspneic. She was in a semiorthopneic position and respirations were accompanied by audible grunting. The pulse was very rapid and the blood pressure was below 70 mm. systolic. Fetal heart tones were absent. The upper abdomen and flanks were quite tender but not spastic. There was marked rebound tenderness. Vaginal examination revealed 5 to 6 cm. dilatation and the presenting head had overriding bones. A paracentesis into the left gutter obtained no blood, but a large amount of blood was quickly obtained from the right gutter. Resuscitative measures, including shock position, Dextran infusion, and later blood transfusions relieved the shock. Under light general anesthesia a laparotomy was performed. Approximately 2,000 cc. of blood was present in the peritoneal cavity. Palpation of the posterior wall of the uterus revealed a small (1 cm. diameter) defect. A rapid low cervical cesarean section was performed and a stillborn infant was delivered. Inspection of the posterior wall then showed three small defects,
Volume Number
83 2
separated 5 to 7 cm. from each other, none of which measured more than 1 cm. in diameter. Because they were thought to be due to placenta percreta, the placenta was not disturbed and a subtotal hysterectomy was performed. The patient withstood the operation very well. The postpartum course was uneventful and she was dismissed on the seventh postoperative day. She was readmitted on the twelfth postoperative day because of fever, chills, and abdominal cramps. These disappeared upon drainage of a cul-de-sac hematoma.
Pathology report. The uterus and cervix together measured 16 by 12 by 10 cm. and weighed 874 grams. On transection the placenta was found to be in place. The stroma remained attached along the posterior wall. On the posterior aspect the placenta, at its point of attachment, was extremely adherent and the wall in this area was thinned to 0.6 cm. in diameter. Three points of uterine wall perforation were demonstrated on the posterior wall separated from each other by a distance of 3 to 4 cm. The points of perforation measured up to 1.5 cm, in diameter, and spongy placental tissue protruded through them. The placental tissue was abundant, soft, spongy, and deep redpurple in color. Microscopy report. Numerous sections were made through the uterine wall to include points of perforation of the wall
Spontaneous
perforations
in term
uterus
251
wherein masses of placental tissue extruded from the endometrial cavity to the surface. Numerous sections were made to determine the presence in all areas of a chorionic plate, and the chorionic plate development was found to be intact and complete. At the areas of perforation the muscular coat of the uterus was extremely thinned and compressed, but no invasion of the muscular coat by placental components was demonstrable. Comment. There was no neoplastic alteration of the placenta or was there a placenta accreta. The marked thinning of the muscle wall in the areas of perforation suggested failure of development of adequate musculature to support the pregnancy and traumatic perforation at the onset of actual labor contractions. Cause for the muscle failure is not known. No actual disease process is demonstrated histologically. Summary This is a case report of a patient who had an obvious hemoperitoneum occurring shortly before or during labor. Three widely separated defects in the posterior uterine wall were found. Pathologically, no evidence of placenta accreta or percreta was present. A curettage had been performed prior to this pregnancy, but there was no evidence that the uterus had been perforated during this procedure.
in a term uterus
A case report
WALTER Middletown,
FENING,
M.D.
Ohio
M u L T I P L E spontaneous perforations in a term uterus with resulting hemoperitoneum and shock is a very unusual and dramatic obstetric complication. When the perforations were recognized at the time of laparotomy, a diagnosis of placenta percreta with intraperitoneal hemorrhage was made. Later, the pathologists could not substantiate a diagnosis of placenta percreta, describing them only as traumatic perforations of undetermined nature. Most of the reported cases of perforations are associated with myomectomy or cesarean scars or postcurettage trauma. In this case there is no evidence that any of these factors pertain. The patient was a 23-year-old white woman, gravida iv, para ii. The first 2 pregnancies resulted in full-term normal infants while the third terminated in a questionable abortion at 8 weeks. Curettings showed only endometritis with no evidence of villi or decidua. Questioning of the physician who performed this curettage 2 years before the present pregnancy and study of the hospital chart failed to reveal anything unusual that might indicate that perforation of the uterus had occurred. The present pregnancy had been uneventful up to the morning of admission. The last menstrual period had occurred on Jan. 29, 1958, and the expected date of delivery was Nov. 6, 1959. About 2 A.M. on Nov. 17, 1959, the patient awakened with pain across the upper abdomen which was steady in character and became increasingly severe. She had several episodes of diarrhea but no dysuria or vaginal bleeding. Fetal movements were not felt after the pain becamr
more severe. She was admitted at 6: 10 A.M. to Middletown hospital having mild uterine contractions and a purulent vaginal discharge, according to the admitting nurse. Cervical dilatation was 4 cm. and the fetal heart tones were recorded as questionably present. The admitting blood pressure was 128/94. She continued to have upper abdominal pain but no strong uterine contractions. By 9:30 A.M. the blood pressure was unobtainable. Digitoxin (0.2 mg.) was given intramuscularly. The pulse rate continued to be 145 per minute and the blood pressure was recorded at various instances to be SO/So. When I saw the patient for the first time, about 11: 30 A.M., she was quite pale and dyspneic. She was in a semiorthopneic position and respirations were accompanied by audible grunting. The pulse was very rapid and the blood pressure was below 70 mm. systolic. Fetal heart tones were absent. The upper abdomen and flanks were quite tender but not spastic. There was marked rebound tenderness. Vaginal examination revealed 5 to 6 cm. dilatation and the presenting head had overriding bones. A paracentesis into the left gutter obtained no blood, but a large amount of blood was quickly obtained from the right gutter. Resuscitative measures, including shock position, Dextran infusion, and later blood transfusions relieved the shock. Under light general anesthesia a laparotomy was performed. Approximately 2,000 cc. of blood was present in the peritoneal cavity. Palpation of the posterior wall of the uterus revealed a small (1 cm. diameter) defect. A rapid low cervical cesarean section was performed and a stillborn infant was delivered. Inspection of the posterior wall then showed three small defects,
Volume Number
83 2
separated 5 to 7 cm. from each other, none of which measured more than 1 cm. in diameter. Because they were thought to be due to placenta percreta, the placenta was not disturbed and a subtotal hysterectomy was performed. The patient withstood the operation very well. The postpartum course was uneventful and she was dismissed on the seventh postoperative day. She was readmitted on the twelfth postoperative day because of fever, chills, and abdominal cramps. These disappeared upon drainage of a cul-de-sac hematoma.
Pathology report. The uterus and cervix together measured 16 by 12 by 10 cm. and weighed 874 grams. On transection the placenta was found to be in place. The stroma remained attached along the posterior wall. On the posterior aspect the placenta, at its point of attachment, was extremely adherent and the wall in this area was thinned to 0.6 cm. in diameter. Three points of uterine wall perforation were demonstrated on the posterior wall separated from each other by a distance of 3 to 4 cm. The points of perforation measured up to 1.5 cm, in diameter, and spongy placental tissue protruded through them. The placental tissue was abundant, soft, spongy, and deep redpurple in color. Microscopy report. Numerous sections were made through the uterine wall to include points of perforation of the wall
Spontaneous
perforations
in term
uterus
251
wherein masses of placental tissue extruded from the endometrial cavity to the surface. Numerous sections were made to determine the presence in all areas of a chorionic plate, and the chorionic plate development was found to be intact and complete. At the areas of perforation the muscular coat of the uterus was extremely thinned and compressed, but no invasion of the muscular coat by placental components was demonstrable. Comment. There was no neoplastic alteration of the placenta or was there a placenta accreta. The marked thinning of the muscle wall in the areas of perforation suggested failure of development of adequate musculature to support the pregnancy and traumatic perforation at the onset of actual labor contractions. Cause for the muscle failure is not known. No actual disease process is demonstrated histologically. Summary This is a case report of a patient who had an obvious hemoperitoneum occurring shortly before or during labor. Three widely separated defects in the posterior uterine wall were found. Pathologically, no evidence of placenta accreta or percreta was present. A curettage had been performed prior to this pregnancy, but there was no evidence that the uterus had been perforated during this procedure.