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Pregnancy complicated by fibromyomas of the lower uterine segment
PREGNANCY
COMPLIC:BTED BY FIBROMYOMSS LOWER UTERINE SEGMENT G.
&~ILTON
POTTER,
S.B., M.D., F.A.C.S.,
BUFFALO,
OF THE N.
Y.
W of
HILE fibrotic conditions of the uterus are not uncommon in pregnant women, it is relatively rare to find large fibromyomas in the lower uterine segment a pregnant uterus at or near t.erm. The following is such a complicated case.
Mrs.
G. H.,
para
Past History :
ii,
gravida
iv:
was admitted
to the
hospital
April
16, 1939.
In
1929 the first child was delivered spontaneously after labor was induced three weeks prematurely by the insertion of a bougie because of hypertension and marked edema. There were no headaches nor visual disturbances. The postpartum course was uneventful. In 1932 a dilatation and curettage was done to interrupt a one and one-half months’ pregnancy because of pernicious vomiting which resulted in marked dehydration. In 1932 she had a spontaneous abortion at three months. In her childhood the patient had measles, chicken pox and scarlatina.
Family History: Her mother and father bot.h died of cancer. A sister had a hysterectomy for uterine fibromyomas. Her menstrual periods began at 14 years with fourto five-day duration of the of age, regular twenty-eight-day cycle, periods. Last menstrual period, Aug. 17, 1935. Term date estimated as Ma) 23, 1939. She gained 26% pounds in weight (128 pounds to 154% pounds). Her She had marked nausea and vomiting appetite was good and bowels were regular. during the first three months, requiring hypodermic medications for sedation. There was moderate leucorrhea but no history of bleeding or dysuria during pregnancy. She had experienced urinary frequency and nocturia prior to admission. For one month before admission, there was edema of the feet and ankles. For three days before admission the patient had severe headaches and slight nausea. There were no visual disturbances, Physical Examination : The blood pressure was 178/106. The patient was a white, well-nourished female. Uterus was the size of an eight months’ pregnancy. Fetal heart tones were 148, left upper quadrant. There was slight edema of feet and ankles. Otherwise the physical examination was negative. The heart was normal. On April 16, 1939, the patient was admitted at lo:30 A.M., with a blood presssure of 192/112, pulse 92. One and one-half grains of nembutal were given. During this day the blood pressure ranged between 162/110 and 175/168. Urinalysis: Specific gravity 1.015, reaction neutral, albumin heavy cloud, sugar 0, acetone 0, casts very rare hyaline and granular, leucocytes moderate amount, many epithelia. Hemoglobin was 80 per cent and red blood count 4,130,000. On Bpril 17, 1939, the blood pressure ranged between 174/110 and l&4/96, and urine showed heavy cloud of albumin every day with a few casts. On April 21, 1939, the patient was examined vaginally, but it was impossible to identify the cervix or its external OS. She was taken to the delivery room for a more complete examination, but still the cervix could not be found. Sfter April 23, 1939, the blood pressure ranged between 144/92 and 192/104. The urine continued a consistently heavy cloud of albumin with a few granular casts. She was having a salt-free diet and 1 ounce of magnesium sulphate every morning. The trend of the blood pressure and the results of the daily urinalysis did not indicate any improvement in the patient’s condition. On April 29, 1939 at 7:30 P.M. the patient began to have a slight bloody show and few cramplike pains. the
1052
POTTER
:
PREGNANCY
COMPLICATED
BY
FIBROMYOMAS
1053
On April 30, 1939, at 1O:OO d.bL the patient was having pains every fifteen min. utes with good contractions. The fetal head was floating above the inlet, and the fetal heart sounds were 148 on the left side of the abdomen above the navel. At The baby’s head was still high and 1O:OO P.M. the blood pressure was 174/124. the intern noted that there seemed to be some obstruction to the progress of the The uterus was oddly Bhaped. Some mechanical obfetal head into the inlet. struction to the normal progress of labor seemed apparent, such as a cervical fibroid. On May 1, 1939, at 12:03 A.M. the patient was taken to surgery and delivered of a living 5pound 4-ounce female child by classical cesarean section. The uterus was closed after delivery of the child, and a panhysterectomy was performed. There was a large fibroid present on the posterior wall of the cervix which was 12 cm. in diameter. Another large fibroid was also present.
Fig.
1.
The blood pressure on return from the operating room was 164/130. The highest temperature postoperatively was 100” F. on the third day. The pulse during the day of the operation and through the fifth postoperative day ranged between 84 and 120. On May 4, 1939, the third postoperative day, about 1:00 P.M., the patient became apprehensive and developed blurred vision. The blood pressure was elevated to 216/136 and the pulse was 120. One-fourth grain of morphine sulphate was given, followed by M cc. doses of Tr. veratrum viride at 3 :15 P.M. At 4:45 P.M. the blood pressure was down to 94/62, and it reached its lowest level of 80/58 at 5:45 P.M. The pulse was 68. At 8:00 P.bf. the patient complained of pain in the right hypochondrium. At 9:00 P.M. the blood pressure was 146/96, pulse, 92. On May 5, 1939, at 8 :30 P.M., the patient again complained of pain in the right hypoThis later moved to the right lumbar area. The patient was voiding chondrium.
sat isfartorily. wise negative.
Urinalyhis
showefl
11e:1\ ,v ~lrru,l
of
all~nmirt.
no casts,
and
111her-
on Mav 16, 393!~, :tt :rhout 5 :OlI l’.M., the patient began to expcriencze a very The temI~hilly feeling and the pulse be~anrc~ estremel~ rapid (160 at 7 : 01) 1T.M.). peraturc rose to 104.L’” F. Thereafter the trrtrperalure gradually returned to normal. Systolic blootl pressure remainecl aroontl I::0 and the urim still showed cvidencc of nephrit&.
The patient that with the good rontlition.
was Ilis~hargetl on tlrr’ twenty-tifth esception of an oc~c~asiional cloud
day. Her family do&or reports of albumin in her urine, she is in
COM;VIlWTS
Demonstrable quent during serious trouble
are relatively tumors of the upper uterine segment pregnancy than is generally supposed, Ijut. as a rule, during deliver)-.
more frodo not cause
Tumors of the lower uterine segment appear to he infrequent, hut when present, during pregnancy at term, challenge the ingenuity and skill of the obstetrician. While it is well known that tumors of the lower uterine segment may be pulled traction of the fundus, up out of the pelvis into the abdomen by the upward this case demonstrates that occasionally this does not happen and obstruction to delivery is the result. This patient seemed to have had none uf the usual prenatal symptoms of sut*h as Iliscomfort. pain, hleeding, and pressure tibroma complicating pregnancy, ,symptomn, but was brought into the hospital and treated lry her family physician, Dr. Wm. Jones, for a toxemia of pregnancy, which evidently from her history, was a toxemia of the nephritic type. fibroids were not suspected, During the medical treatment of the toxemia, and it w&s not until the onset of labor that the intern and the family physician noticed the abnormal shape of the uterus during contractions, and consultation was sought. A definite hard mass had appeared above the symphysis which had The fetal heart sounds remained rapid pushed the head higher up and anterior. in the upper left quadrant. At this time the cervix could not tie located by vaginal examination lmt, a hard mass could be felt higher up, Realizing that an obvious mechanical dystocia was present after the possibility of a t,win pregnancy, an ovarian cyst or an overdistended bladder was ruletl out, it was evident that we were dealing with a large fibroma or fihromas of the lower uterine segment and that during labor the lower uterine segment was partially pulled up and the uterus had rotated. This torsion or partial rotation of the uterus ~mlled the til~roids, which were posterior and lateral, into more of an anterior position, so that. t.hey could be felt above the spmphysis. A high classical cesarean section was immediately performed, after which it This was was discovered that the tumor mass could be dislodged and removed. Fig. 1 illustrates the size and exteut of the frljroids and the imprardone. ticability of leaving the uterus. The patient recorered after :I storm,v convalescence and returned home with a live baby. MILLARD
FILLMORE
HOSPITAL
COMPLIC:BTED BY FIBROMYOMSS LOWER UTERINE SEGMENT G.
&~ILTON
POTTER,
S.B., M.D., F.A.C.S.,
BUFFALO,
OF THE N.
Y.
W of
HILE fibrotic conditions of the uterus are not uncommon in pregnant women, it is relatively rare to find large fibromyomas in the lower uterine segment a pregnant uterus at or near t.erm. The following is such a complicated case.
Mrs.
G. H.,
para
Past History :
ii,
gravida
iv:
was admitted
to the
hospital
April
16, 1939.
In
1929 the first child was delivered spontaneously after labor was induced three weeks prematurely by the insertion of a bougie because of hypertension and marked edema. There were no headaches nor visual disturbances. The postpartum course was uneventful. In 1932 a dilatation and curettage was done to interrupt a one and one-half months’ pregnancy because of pernicious vomiting which resulted in marked dehydration. In 1932 she had a spontaneous abortion at three months. In her childhood the patient had measles, chicken pox and scarlatina.
Family History: Her mother and father bot.h died of cancer. A sister had a hysterectomy for uterine fibromyomas. Her menstrual periods began at 14 years with fourto five-day duration of the of age, regular twenty-eight-day cycle, periods. Last menstrual period, Aug. 17, 1935. Term date estimated as Ma) 23, 1939. She gained 26% pounds in weight (128 pounds to 154% pounds). Her She had marked nausea and vomiting appetite was good and bowels were regular. during the first three months, requiring hypodermic medications for sedation. There was moderate leucorrhea but no history of bleeding or dysuria during pregnancy. She had experienced urinary frequency and nocturia prior to admission. For one month before admission, there was edema of the feet and ankles. For three days before admission the patient had severe headaches and slight nausea. There were no visual disturbances, Physical Examination : The blood pressure was 178/106. The patient was a white, well-nourished female. Uterus was the size of an eight months’ pregnancy. Fetal heart tones were 148, left upper quadrant. There was slight edema of feet and ankles. Otherwise the physical examination was negative. The heart was normal. On April 16, 1939, the patient was admitted at lo:30 A.M., with a blood presssure of 192/112, pulse 92. One and one-half grains of nembutal were given. During this day the blood pressure ranged between 162/110 and 175/168. Urinalysis: Specific gravity 1.015, reaction neutral, albumin heavy cloud, sugar 0, acetone 0, casts very rare hyaline and granular, leucocytes moderate amount, many epithelia. Hemoglobin was 80 per cent and red blood count 4,130,000. On Bpril 17, 1939, the blood pressure ranged between 174/110 and l&4/96, and urine showed heavy cloud of albumin every day with a few casts. On April 21, 1939, the patient was examined vaginally, but it was impossible to identify the cervix or its external OS. She was taken to the delivery room for a more complete examination, but still the cervix could not be found. Sfter April 23, 1939, the blood pressure ranged between 144/92 and 192/104. The urine continued a consistently heavy cloud of albumin with a few granular casts. She was having a salt-free diet and 1 ounce of magnesium sulphate every morning. The trend of the blood pressure and the results of the daily urinalysis did not indicate any improvement in the patient’s condition. On April 29, 1939 at 7:30 P.M. the patient began to have a slight bloody show and few cramplike pains. the
1052
POTTER
:
PREGNANCY
COMPLICATED
BY
FIBROMYOMAS
1053
On April 30, 1939, at 1O:OO d.bL the patient was having pains every fifteen min. utes with good contractions. The fetal head was floating above the inlet, and the fetal heart sounds were 148 on the left side of the abdomen above the navel. At The baby’s head was still high and 1O:OO P.M. the blood pressure was 174/124. the intern noted that there seemed to be some obstruction to the progress of the The uterus was oddly Bhaped. Some mechanical obfetal head into the inlet. struction to the normal progress of labor seemed apparent, such as a cervical fibroid. On May 1, 1939, at 12:03 A.M. the patient was taken to surgery and delivered of a living 5pound 4-ounce female child by classical cesarean section. The uterus was closed after delivery of the child, and a panhysterectomy was performed. There was a large fibroid present on the posterior wall of the cervix which was 12 cm. in diameter. Another large fibroid was also present.
Fig.
1.
The blood pressure on return from the operating room was 164/130. The highest temperature postoperatively was 100” F. on the third day. The pulse during the day of the operation and through the fifth postoperative day ranged between 84 and 120. On May 4, 1939, the third postoperative day, about 1:00 P.M., the patient became apprehensive and developed blurred vision. The blood pressure was elevated to 216/136 and the pulse was 120. One-fourth grain of morphine sulphate was given, followed by M cc. doses of Tr. veratrum viride at 3 :15 P.M. At 4:45 P.M. the blood pressure was down to 94/62, and it reached its lowest level of 80/58 at 5:45 P.M. The pulse was 68. At 8:00 P.bf. the patient complained of pain in the right hypochondrium. At 9:00 P.M. the blood pressure was 146/96, pulse, 92. On May 5, 1939, at 8 :30 P.M., the patient again complained of pain in the right hypoThis later moved to the right lumbar area. The patient was voiding chondrium.
sat isfartorily. wise negative.
Urinalyhis
showefl
11e:1\ ,v ~lrru,l
of
all~nmirt.
no casts,
and
111her-
on Mav 16, 393!~, :tt :rhout 5 :OlI l’.M., the patient began to expcriencze a very The temI~hilly feeling and the pulse be~anrc~ estremel~ rapid (160 at 7 : 01) 1T.M.). peraturc rose to 104.L’” F. Thereafter the trrtrperalure gradually returned to normal. Systolic blootl pressure remainecl aroontl I::0 and the urim still showed cvidencc of nephrit&.
The patient that with the good rontlition.
was Ilis~hargetl on tlrr’ twenty-tifth esception of an oc~c~asiional cloud
day. Her family do&or reports of albumin in her urine, she is in
COM;VIlWTS
Demonstrable quent during serious trouble
are relatively tumors of the upper uterine segment pregnancy than is generally supposed, Ijut. as a rule, during deliver)-.
more frodo not cause
Tumors of the lower uterine segment appear to he infrequent, hut when present, during pregnancy at term, challenge the ingenuity and skill of the obstetrician. While it is well known that tumors of the lower uterine segment may be pulled traction of the fundus, up out of the pelvis into the abdomen by the upward this case demonstrates that occasionally this does not happen and obstruction to delivery is the result. This patient seemed to have had none uf the usual prenatal symptoms of sut*h as Iliscomfort. pain, hleeding, and pressure tibroma complicating pregnancy, ,symptomn, but was brought into the hospital and treated lry her family physician, Dr. Wm. Jones, for a toxemia of pregnancy, which evidently from her history, was a toxemia of the nephritic type. fibroids were not suspected, During the medical treatment of the toxemia, and it w&s not until the onset of labor that the intern and the family physician noticed the abnormal shape of the uterus during contractions, and consultation was sought. A definite hard mass had appeared above the symphysis which had The fetal heart sounds remained rapid pushed the head higher up and anterior. in the upper left quadrant. At this time the cervix could not tie located by vaginal examination lmt, a hard mass could be felt higher up, Realizing that an obvious mechanical dystocia was present after the possibility of a t,win pregnancy, an ovarian cyst or an overdistended bladder was ruletl out, it was evident that we were dealing with a large fibroma or fihromas of the lower uterine segment and that during labor the lower uterine segment was partially pulled up and the uterus had rotated. This torsion or partial rotation of the uterus ~mlled the til~roids, which were posterior and lateral, into more of an anterior position, so that. t.hey could be felt above the spmphysis. A high classical cesarean section was immediately performed, after which it This was was discovered that the tumor mass could be dislodged and removed. Fig. 1 illustrates the size and exteut of the frljroids and the imprardone. ticability of leaving the uterus. The patient recorered after :I storm,v convalescence and returned home with a live baby. MILLARD
FILLMORE
HOSPITAL