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Oligohydramnios in relation to roentgen signs of fetal death
OLIGOHYDRAMNIOS SIGNS OF FETAL
IN DEATH
RELATION
TO ROENTGEN
Case Report BELA DAVID (From
the Departments
of Radiology
K.
S.
KENT,
M.D.,
SIDNEY
DANN,
M.D.,
KANSAS
and of Obstetrics,
Menorah
Medical
KUBIN,
M.D.,
CITY,
Mo.
AND
Center)
T
HE diagnosis of fetal death by the obstetrician or the roentgenologist This case is presented because the roentoffers certain definite hazards. gen signs were misleading, due to the presence of oligohydramnios. We hope to alert other radiologists and obstetricians to the pitfalls in attempting to diagnose fetal viability in the presence of this obstetrical complication. Mrs. E. Y., a 25year-old para ii, gravida ii, had her last menstrual period on Nov. 2, 1952. In December, 1952, she had some vaginal bleeding which stopped within a few days. On April 16, 1953, she was admitted to the hospital with vaginal bleeding. Although the patient claimed she felt life, no fetal heart sounds were hearcl. The uterus was smaller than the expected size. The bleeding stopped and she was dismisse(l on April 19. She continued to feel life and the heart tones were occasionally detectable, but the uterus did not become larger. On April 23 roentgenograms made in the supine and upright positions revealed loss of tone of the fetus, suggesting a nonviable fetus (Figs. 1 and 2). The patient continued to bleed intermittently, with occasional cramps. In llay~, t,he uterus At this time, she felt life and good feta1 heart tones were had not enlarged noticeably. heard. On May 10 she was readmitted to the hospital with bleeding and contractions. Despite the usual treatment, she The uterus was no larger than a 4 months’ pregnancy. started to have regular labor pains on May 12 and 7 hours later expelled the intact amThe sac was opened and no amniotic fluid except about niotic sac and placenta together. The baby was alive and crietl one tablespoonful of thick mucoid material was founcl. spontaneously. ‘The source of the bleeding was not founcl. The baby weighed 1 pound, On the third day an attempt was made to put 11 ounces and was placed in an incubator. Shortly thereafter, the baby a catheter into the baby’s stomach for feeding purposes. became cyanotic and died.
Comment The multiplicity of theories regarding the development of oligohydramnios can be readily compared to the many roentgen signs of fetal death.‘-5 This should only emphasize the lack of reliability of any single criterion in are the usual roentgen signs of fetal death: either case. The following (1) Spalding’sl sign (overlapping of sutures in absence of labor) ; (2) flattening of the vault of the skull ; (3) asymmetry of the skull ; (4) marked curvature or angulation of the spine ; (5) indistinct bone markings ; (6) failure of the fetus to change position following repeated s-ray exposures; (7) The “halo sign” due to the separation of the scalp from the bony skull; (8) gas in the fetal circulatory system. TageP offered a new sign based on an extremely simple technique in which the diagnosis of intrauterine death is easily established. In all cases 1106
~;;liun~;~;+
OLTGOHYDRAMNIOS
AND
ROENTGEN
SIGNS
OF
FETAL
DEATH
1107
where the question of fetal death is raised by either the obstetrician or the radiologist, two films are taken. One is a routine anteropostcrior projection with the patient supine, and the other with the patient upright, anteroposterior. In the examination of the films, particular attention is directed to the fetal spine, since it offers the easiest landmark. If the roentgenogram in the upright position reveals a complete collapse of the spine into the pelvic area, it is considcrcd pathognomonic of fetal death, constituting the particular sign presented here.
Fig. Fig. Fig.
l.-Film Z.-Film
1.
in the supine in the upright
Fig. position. position
demonstrating
fetal
2.
collapse.
In our case of oligohydramnios this so-called pathognomonic sign of fetal death was present, yet the fetus was viable. .The error was made by misinterpreting the distortion of the fetus and the completely collapsed spine. It is apparent that this sign as well as all the prevailing diagnostic roentgen signs of fetal viability have their exceptions. It is our desire to record the importance of recognizing this complication in the presence of the so-called pathognomonia sign of Tager.
References Am. J. Roentgenol. 62: 837, 1949. 1. Davidson, C. N.: 2. DeLee, J. B.: The Principles and Practice of Obstetrics, ed. 7, Philadelphia, 1938, W. B. Saunders Company, p. 306. 3. Spalding, A. B.: Surg., Gynec. & Obst. 34: 754, 1922. 4. Schmiemann, R.: Zentralbl. GynGk. 62: 377, 1939. 5. Schnitker, M. A., Hodges, P. C., and Whiteacre, F. E.: Am. J. Roentgenol. 28: 349, 1932. 67: 106, 1954. 6. Tager, N. S.: Am. 5. Roentgenol.
IN DEATH
RELATION
TO ROENTGEN
Case Report BELA DAVID (From
the Departments
of Radiology
K.
S.
KENT,
M.D.,
SIDNEY
DANN,
M.D.,
KANSAS
and of Obstetrics,
Menorah
Medical
KUBIN,
M.D.,
CITY,
Mo.
AND
Center)
T
HE diagnosis of fetal death by the obstetrician or the roentgenologist This case is presented because the roentoffers certain definite hazards. gen signs were misleading, due to the presence of oligohydramnios. We hope to alert other radiologists and obstetricians to the pitfalls in attempting to diagnose fetal viability in the presence of this obstetrical complication. Mrs. E. Y., a 25year-old para ii, gravida ii, had her last menstrual period on Nov. 2, 1952. In December, 1952, she had some vaginal bleeding which stopped within a few days. On April 16, 1953, she was admitted to the hospital with vaginal bleeding. Although the patient claimed she felt life, no fetal heart sounds were hearcl. The uterus was smaller than the expected size. The bleeding stopped and she was dismisse(l on April 19. She continued to feel life and the heart tones were occasionally detectable, but the uterus did not become larger. On April 23 roentgenograms made in the supine and upright positions revealed loss of tone of the fetus, suggesting a nonviable fetus (Figs. 1 and 2). The patient continued to bleed intermittently, with occasional cramps. In llay~, t,he uterus At this time, she felt life and good feta1 heart tones were had not enlarged noticeably. heard. On May 10 she was readmitted to the hospital with bleeding and contractions. Despite the usual treatment, she The uterus was no larger than a 4 months’ pregnancy. started to have regular labor pains on May 12 and 7 hours later expelled the intact amThe sac was opened and no amniotic fluid except about niotic sac and placenta together. The baby was alive and crietl one tablespoonful of thick mucoid material was founcl. spontaneously. ‘The source of the bleeding was not founcl. The baby weighed 1 pound, On the third day an attempt was made to put 11 ounces and was placed in an incubator. Shortly thereafter, the baby a catheter into the baby’s stomach for feeding purposes. became cyanotic and died.
Comment The multiplicity of theories regarding the development of oligohydramnios can be readily compared to the many roentgen signs of fetal death.‘-5 This should only emphasize the lack of reliability of any single criterion in are the usual roentgen signs of fetal death: either case. The following (1) Spalding’sl sign (overlapping of sutures in absence of labor) ; (2) flattening of the vault of the skull ; (3) asymmetry of the skull ; (4) marked curvature or angulation of the spine ; (5) indistinct bone markings ; (6) failure of the fetus to change position following repeated s-ray exposures; (7) The “halo sign” due to the separation of the scalp from the bony skull; (8) gas in the fetal circulatory system. TageP offered a new sign based on an extremely simple technique in which the diagnosis of intrauterine death is easily established. In all cases 1106
~;;liun~;~;+
OLTGOHYDRAMNIOS
AND
ROENTGEN
SIGNS
OF
FETAL
DEATH
1107
where the question of fetal death is raised by either the obstetrician or the radiologist, two films are taken. One is a routine anteropostcrior projection with the patient supine, and the other with the patient upright, anteroposterior. In the examination of the films, particular attention is directed to the fetal spine, since it offers the easiest landmark. If the roentgenogram in the upright position reveals a complete collapse of the spine into the pelvic area, it is considcrcd pathognomonic of fetal death, constituting the particular sign presented here.
Fig. Fig. Fig.
l.-Film Z.-Film
1.
in the supine in the upright
Fig. position. position
demonstrating
fetal
2.
collapse.
In our case of oligohydramnios this so-called pathognomonic sign of fetal death was present, yet the fetus was viable. .The error was made by misinterpreting the distortion of the fetus and the completely collapsed spine. It is apparent that this sign as well as all the prevailing diagnostic roentgen signs of fetal viability have their exceptions. It is our desire to record the importance of recognizing this complication in the presence of the so-called pathognomonia sign of Tager.
References Am. J. Roentgenol. 62: 837, 1949. 1. Davidson, C. N.: 2. DeLee, J. B.: The Principles and Practice of Obstetrics, ed. 7, Philadelphia, 1938, W. B. Saunders Company, p. 306. 3. Spalding, A. B.: Surg., Gynec. & Obst. 34: 754, 1922. 4. Schmiemann, R.: Zentralbl. GynGk. 62: 377, 1939. 5. Schnitker, M. A., Hodges, P. C., and Whiteacre, F. E.: Am. J. Roentgenol. 28: 349, 1932. 67: 106, 1954. 6. Tager, N. S.: Am. 5. Roentgenol.