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Patient presentations: Panel discussion
Patient presentatio"ls
Volume 12:·; :\umber I
musculature may predispose to the occurrence of uterine torsion. The symptoms of malrotation are myriad and are not unique enough to warrant a primary diagnosis, nor are the clinical signs definite enough to make them predictable. Acute torsion with abdominal pain, vaginal bleeding, and shock would make one consider abruptio placentae primarily. The presence of urethral displacement, twisted vaginal canal, anteriorly displaced uterine artery, and normal fibrinolytic studies with the absence of a depressed fibrinogen may be of diagnostic significance. Quite frequently these signs may be representative of hindsight observations. 2 • 4 • s10, 13. 16
Nowhere in the literature is the duration of symptoms mentioned with any certainty. Most cases appear to have a fairly acute onset and mimic an acute abdominal episode. 18 One case reported presented as an acute intestinal obstruction. 15 In the case reported by this author, the symptoms of abdominal pain, vaginal bleeding, and intermittent urinary obstruction had been present for several weeks. This is not meant to suggest that extreme torsion had been present for that period of time, yet it is reasonable to presume that a prodromal torsion greater than normal did exist prior to the onset of the catastrophic phase. Maternal and fetal mortality rates are well documented. The maternal mortality rate averages 13.2 per cent, with little variation as to stage of gestation. 1 The fetal mortality rate is approximately 30 per cent and seems directly proportional to the stage of gestation and degree of torsion. 1 As in the majority of cases reported, the diagnosis in this instance was made at the time of laparotomy.
REFERENCES
5.
.J.: Manuel de Gynecologic pratique, Paris, 1907. Cited by Nesbitt and Corner. Carter, T. D.: Cent. Afr. J. Med. 7: 258, 1961. Greening. J. R., and Beck, R. P.: Obstet. Gynecol. 21: 421, 1963. Imrie, A. H.: J. Obstet. Gynaecol. Br- Commonw. 73: 1022, 1963. Kosugi, A., et al.: Sonfujin Jissai. 14: 1033, 1965.
C.
TJ ______ .. : _ _
U,
l\.UVU~UIJd
I. Barrozzi,
2. 3. 4.
1 V _ .. _1 . 1 1. 1\.., Cl dl.;
..t.L ___ L 1"\.KU~U.
ro: __ l__l
\JlllCKUl,
Al'l. 10"'
lf"'U:!t::
~J.;
l~U~.
l;JI,
7. Labbe, L.: Lecons de clinque chirurgicale professees a l'hopital des cliniques, Paris, 1876. Cited by Nesbitt and Corner. 8. Lipinski, A.: Wiad. Lek. 22: 567, 1969. 9. MesaLL, T., et al.: Rev. Clin. Inst. Matern. 18: 195, 1967. I 0. Mitchell. P. R.: J. Obstet. Gynaecol. Br. Emp. 67: 654, 1960. 11. Nesbitt, R. E. L., Jr., and Corner, G. W.: Obstet. Gynecol. Surv. 11:311, 1956. 12. Nowosielski, P. F., and Henderson, H.: AM. J. 0BSTET GYNECOL. 80: 270, 1960.
33
13. Poluikh, A. F.: Akush. Ginekol. 41: 147. 1965. 14. Robinson, A. L., and Duvall, H. M.: J. Obstet. G~naecol. Br. Emp. 38: 55, 1931. 15. Sciolo, F., et al.: P~ss Int. Clin. Ter. 46: 541. 1966. 16. Szlapak, K.: Gynaecologia 150:47, 1960. 17. Virchow, R.: Die krankhaften Geschwulste, III, 863. 18. Wennemann. C.: Geburtshi1fe Frauenheiikd. 29: 667. 1969.
Term pregnancy in a patient with myelomeningocele, uretero-ileostomy, and parna1 paraparesis . •
1
•
F. E. ELLiSON. jR., M.D. GreenvillR, South Carolina
in a patient with urinary diversion is an uncommon problem. Only 84 patients had been reported by 1972 who had favorable maternal and perinatal outcomes. Nine of these patients had had uretero-ileostomy; the others had had uretero-~igmoid ostomy, ileo-cystoplasty, uretero-cutaneostorny, and pelvio-cystoplasty. 1 This case report describes a pregnancy complicated by uretero-ileostomy, neural tube malformation, and a slight degree of paralysis affecting the lower extremities. PREGNANCY
The patient was a 30-year-old white woman, gravida 1, para 0. She was seen on April 25. 1973, stating that her last menstrual period had been on February 4, 1973, making her estimated date of confinement November II, 1973. At her birth she had a large lumbosacral myelomf·ningocele with paraparesis. A few days after birth the defect was repaired. She was treated by several orthopedists a•1d underwent extensive bracing over the years. allowing her to walk with crutches. Because of a neurogenic bladder and chronic pyelonephritis, uretero-ileostomy was done in 1960 when she was 16 years old. In 1970, the myelomeningocele, measuring 36 inches in circumference at the base, was repaired. Physical examination on April 25, 1973, confir!Tled a pregnancy of 8 to 10 weeks' gestation. Pelvic exambation was difficult, since she could abduct her lower extremities only enough to allow her feet to be separated about 10 inches. The ileostomy stoma was on the right. The lower trunk and lower extremities were small, with full-length braces on the lower extremities. There was no motion below the knees, with partial function of the hip flexors and extensors of the Presented as official guest at the Thirty-seventh Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, February 2-5, 1975. Reprint requests: Dr. F. E. Ellison, Jr., 12 South Leach St., Greenville. South Carolina 29601.
34
Patient presentations
knees and flexors of the thighs. She had no sensation in the dermatomes of L5 through the coccygeal dermatomes. Sulfisoxazole, which had been started by her urologist, was continued until June, 1973, when a urine culture grew a mixed infection of Pseudomonas and Proteus mirabilis. The blood urea nitrogen (BUN) was 8 mg. per 100 mi.; creatinine was 0.6 mg. per 100 mi. She was hospitalized and treated with gentamicin. After discharge, she received nitrofurantoin macrocrystals until October 26, 1973, when she required hospitalization because of 103.6° temperature. Laboratory data showed a hemoglobin of 11.5 Gm., hematocrit of 34 per cent, and white blood cells of 20,500 with a shift to the left. BUN was 11 mg. per 100 mi.; creatinine was 0.8 mg. per 100 mi. Specific gravity of the urine was 1.011, albumin was 2 plus, and white blood cells were 1 to 3. Proteus ·mirabilis was cultured from the urine. She was treated with intravenous cephalothin with good results. Repeat hematology examination 4 days after admission was normal. X-ray studies on November 1, 1973, showed a fetus near term. Dye was injected into the stoma of the ileostomy. The loop was posterolateral and separate from the uterus. Due to recurrent kidney infection and inability to adequately abduct the lower extremities, a classical cesarean section and bilateral partial salpingectomy (Pomeroy) were done on November 2, 1973. An apparently normal 2,750 gram male infant with an Apgar score of 9 was delivered. His growth and development have been normal. The patient's immediate postpartum course was uneventful. However, 2 months later, renal stones were identified by an intravenous pyelogram. She subsequently underwent transabdominal bilateral ureterolithotomy with good results.
The outcome of a pregnancy with uretero-ileostomy depends on the underlying cause for the urinary diversion. Any abnormal renal function is aggravated by
I. ]<17:) Oh.\lcl. (;uJ<•to!.
.~cptcmht·J
.-\m.
J
the pregnancy, thus altering the prognosis. 2 Therefore, the renal status must be monitored closely and treated accordingly. If abnormaL the patient should have therapeutic abortion. 1 The fetal prognosis depends on why the urinary diversion was done. Most of the other reported cases were done for extrophy of the bladder, vesicovaginal fistula, and shrunken bladder. In 1973, Carter and Evans 3 combined their four patients with neural tube defects with the 29 cases of Tlinte and estimated the risk to the offspring to be 3 per cent. Patients with paraplegia can have normal labor and delivery. 4 All of the other patients with uretero-ileostomy delivered vaginally. Cesarean section should be done only for obstetric indications. Vaginal delivery was not possible for this patient because of the paraparesis. Uretero-ileostomy, myelomeningocele, and paraparesis are not absolute contraindications for pregnancy. These patients should be evaluated prior to pregnancy, if possible, noting the cause for the urinary diversion and the renal status. During the pregnancy, any change in the stoma, such as stenosis or retraction, must be corrected. The main complication, acute infection of the kidney, must be treated vigorously. 4 REFERENCES l. Olesen, S.: Dan. ~..1ed. BulL 19: 108, 1972. 2. Pedlow, P. R. B.: J. Obstet. Gynaecol. Br. Commonw. 68: 822, 1961. 3. Carter, C. 0., and Evans, K.: Lancet 2: 924, 1973. 4. Daw, E.: Practitioner 211: 781, 1973.
Volume 12:·; :\umber I
musculature may predispose to the occurrence of uterine torsion. The symptoms of malrotation are myriad and are not unique enough to warrant a primary diagnosis, nor are the clinical signs definite enough to make them predictable. Acute torsion with abdominal pain, vaginal bleeding, and shock would make one consider abruptio placentae primarily. The presence of urethral displacement, twisted vaginal canal, anteriorly displaced uterine artery, and normal fibrinolytic studies with the absence of a depressed fibrinogen may be of diagnostic significance. Quite frequently these signs may be representative of hindsight observations. 2 • 4 • s10, 13. 16
Nowhere in the literature is the duration of symptoms mentioned with any certainty. Most cases appear to have a fairly acute onset and mimic an acute abdominal episode. 18 One case reported presented as an acute intestinal obstruction. 15 In the case reported by this author, the symptoms of abdominal pain, vaginal bleeding, and intermittent urinary obstruction had been present for several weeks. This is not meant to suggest that extreme torsion had been present for that period of time, yet it is reasonable to presume that a prodromal torsion greater than normal did exist prior to the onset of the catastrophic phase. Maternal and fetal mortality rates are well documented. The maternal mortality rate averages 13.2 per cent, with little variation as to stage of gestation. 1 The fetal mortality rate is approximately 30 per cent and seems directly proportional to the stage of gestation and degree of torsion. 1 As in the majority of cases reported, the diagnosis in this instance was made at the time of laparotomy.
REFERENCES
5.
.J.: Manuel de Gynecologic pratique, Paris, 1907. Cited by Nesbitt and Corner. Carter, T. D.: Cent. Afr. J. Med. 7: 258, 1961. Greening. J. R., and Beck, R. P.: Obstet. Gynecol. 21: 421, 1963. Imrie, A. H.: J. Obstet. Gynaecol. Br- Commonw. 73: 1022, 1963. Kosugi, A., et al.: Sonfujin Jissai. 14: 1033, 1965.
C.
TJ ______ .. : _ _
U,
l\.UVU~UIJd
I. Barrozzi,
2. 3. 4.
1 V _ .. _1 . 1 1. 1\.., Cl dl.;
..t.L ___ L 1"\.KU~U.
ro: __ l__l
\JlllCKUl,
Al'l. 10"'
lf"'U:!t::
~J.;
l~U~.
l;JI,
7. Labbe, L.: Lecons de clinque chirurgicale professees a l'hopital des cliniques, Paris, 1876. Cited by Nesbitt and Corner. 8. Lipinski, A.: Wiad. Lek. 22: 567, 1969. 9. MesaLL, T., et al.: Rev. Clin. Inst. Matern. 18: 195, 1967. I 0. Mitchell. P. R.: J. Obstet. Gynaecol. Br. Emp. 67: 654, 1960. 11. Nesbitt, R. E. L., Jr., and Corner, G. W.: Obstet. Gynecol. Surv. 11:311, 1956. 12. Nowosielski, P. F., and Henderson, H.: AM. J. 0BSTET GYNECOL. 80: 270, 1960.
33
13. Poluikh, A. F.: Akush. Ginekol. 41: 147. 1965. 14. Robinson, A. L., and Duvall, H. M.: J. Obstet. G~naecol. Br. Emp. 38: 55, 1931. 15. Sciolo, F., et al.: P~ss Int. Clin. Ter. 46: 541. 1966. 16. Szlapak, K.: Gynaecologia 150:47, 1960. 17. Virchow, R.: Die krankhaften Geschwulste, III, 863. 18. Wennemann. C.: Geburtshi1fe Frauenheiikd. 29: 667. 1969.
Term pregnancy in a patient with myelomeningocele, uretero-ileostomy, and parna1 paraparesis . •
1
•
F. E. ELLiSON. jR., M.D. GreenvillR, South Carolina
in a patient with urinary diversion is an uncommon problem. Only 84 patients had been reported by 1972 who had favorable maternal and perinatal outcomes. Nine of these patients had had uretero-ileostomy; the others had had uretero-~igmoid ostomy, ileo-cystoplasty, uretero-cutaneostorny, and pelvio-cystoplasty. 1 This case report describes a pregnancy complicated by uretero-ileostomy, neural tube malformation, and a slight degree of paralysis affecting the lower extremities. PREGNANCY
The patient was a 30-year-old white woman, gravida 1, para 0. She was seen on April 25. 1973, stating that her last menstrual period had been on February 4, 1973, making her estimated date of confinement November II, 1973. At her birth she had a large lumbosacral myelomf·ningocele with paraparesis. A few days after birth the defect was repaired. She was treated by several orthopedists a•1d underwent extensive bracing over the years. allowing her to walk with crutches. Because of a neurogenic bladder and chronic pyelonephritis, uretero-ileostomy was done in 1960 when she was 16 years old. In 1970, the myelomeningocele, measuring 36 inches in circumference at the base, was repaired. Physical examination on April 25, 1973, confir!Tled a pregnancy of 8 to 10 weeks' gestation. Pelvic exambation was difficult, since she could abduct her lower extremities only enough to allow her feet to be separated about 10 inches. The ileostomy stoma was on the right. The lower trunk and lower extremities were small, with full-length braces on the lower extremities. There was no motion below the knees, with partial function of the hip flexors and extensors of the Presented as official guest at the Thirty-seventh Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, February 2-5, 1975. Reprint requests: Dr. F. E. Ellison, Jr., 12 South Leach St., Greenville. South Carolina 29601.
34
Patient presentations
knees and flexors of the thighs. She had no sensation in the dermatomes of L5 through the coccygeal dermatomes. Sulfisoxazole, which had been started by her urologist, was continued until June, 1973, when a urine culture grew a mixed infection of Pseudomonas and Proteus mirabilis. The blood urea nitrogen (BUN) was 8 mg. per 100 mi.; creatinine was 0.6 mg. per 100 mi. She was hospitalized and treated with gentamicin. After discharge, she received nitrofurantoin macrocrystals until October 26, 1973, when she required hospitalization because of 103.6° temperature. Laboratory data showed a hemoglobin of 11.5 Gm., hematocrit of 34 per cent, and white blood cells of 20,500 with a shift to the left. BUN was 11 mg. per 100 mi.; creatinine was 0.8 mg. per 100 mi. Specific gravity of the urine was 1.011, albumin was 2 plus, and white blood cells were 1 to 3. Proteus ·mirabilis was cultured from the urine. She was treated with intravenous cephalothin with good results. Repeat hematology examination 4 days after admission was normal. X-ray studies on November 1, 1973, showed a fetus near term. Dye was injected into the stoma of the ileostomy. The loop was posterolateral and separate from the uterus. Due to recurrent kidney infection and inability to adequately abduct the lower extremities, a classical cesarean section and bilateral partial salpingectomy (Pomeroy) were done on November 2, 1973. An apparently normal 2,750 gram male infant with an Apgar score of 9 was delivered. His growth and development have been normal. The patient's immediate postpartum course was uneventful. However, 2 months later, renal stones were identified by an intravenous pyelogram. She subsequently underwent transabdominal bilateral ureterolithotomy with good results.
The outcome of a pregnancy with uretero-ileostomy depends on the underlying cause for the urinary diversion. Any abnormal renal function is aggravated by
I. ]<17:) Oh.\lcl. (;uJ<•to!.
.~cptcmht·J
.-\m.
J
the pregnancy, thus altering the prognosis. 2 Therefore, the renal status must be monitored closely and treated accordingly. If abnormaL the patient should have therapeutic abortion. 1 The fetal prognosis depends on why the urinary diversion was done. Most of the other reported cases were done for extrophy of the bladder, vesicovaginal fistula, and shrunken bladder. In 1973, Carter and Evans 3 combined their four patients with neural tube defects with the 29 cases of Tlinte and estimated the risk to the offspring to be 3 per cent. Patients with paraplegia can have normal labor and delivery. 4 All of the other patients with uretero-ileostomy delivered vaginally. Cesarean section should be done only for obstetric indications. Vaginal delivery was not possible for this patient because of the paraparesis. Uretero-ileostomy, myelomeningocele, and paraparesis are not absolute contraindications for pregnancy. These patients should be evaluated prior to pregnancy, if possible, noting the cause for the urinary diversion and the renal status. During the pregnancy, any change in the stoma, such as stenosis or retraction, must be corrected. The main complication, acute infection of the kidney, must be treated vigorously. 4 REFERENCES l. Olesen, S.: Dan. ~..1ed. BulL 19: 108, 1972. 2. Pedlow, P. R. B.: J. Obstet. Gynaecol. Br. Commonw. 68: 822, 1961. 3. Carter, C. 0., and Evans, K.: Lancet 2: 924, 1973. 4. Daw, E.: Practitioner 211: 781, 1973.