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Pregnancy Complicated by Severe Gastric Hemorrhage
PREGNANCY COMPLICATED BY SEVERE GASTRIC HEMORRHAGE ARTHUR
v.
GREELEY, M.D., AND WILLIAM D. STUBENBORD, M.D., NEW YORK, N. Y.
(From the New York Hospital
11/Ml
Cornell University and Mediool College)
following ease is being reported because of the rare occurrence of severe T HE gastric hemorrhage occurring in a pregnant woman at term. Only two reports could be found in the literature on similar types of cases, and no mention of the subject could be found in any of the standard textbooks on obstetrics. Sturrock,l in 1913, reported a case of gastric hemorrhage occurring at the time of delivery, but this case was m no way comparable to the one we are reporting. Subsequent studies were not done and no adequate explanation was given for its cause. Preiss,z in 1907, reported the case of a woman who had a similar accident in her second and third pregnancies. Her first pregnancy was entirely normal. The second pregnancy, fifteen months later, and the third, three years after the second, were complicated by the occurrence of sudden severe gastrointestinal hemorrhages evidenced by vomiting of blood, passage of bloody stools, and shock. In both pregnancies, the bleeding occurred about two weeks before the expected date of confinement and was not associated with any previous gastrointestinal symptoms. In both instances, the onset of labor and delivery were spontaneous within twenty-four hours after the bleeding. The birth of normal, deadborn, male infants was the result in both pregnancies; the fetal hearts were lost during labor without any apparent cause. The puerperiums were normal in both pregnancies, and in the second pregnancy no special diet was given. The author discusses the possible causes of the bleeding and comes to the conclusion that it was due to a ruptured gastric varix produced by the mechanical stimulation of solid food. Contrary to our experience, both Sturrock and Preiss make the statement that gastrointestinal hemorrhage during pregnancy i~ not an uncommon complication. In going over the records of the New York Hospital and the Berwind Maternity Clinic, no such complication occurred during labor in 27,942 deliveries. There was, however, one caFe of moderately severe hematemesis in a five months pregnant woman, who improved on bed rest and diet and went to term without further complications. Our patient was a 31-year-old gravida ii, para i, who was admitted to the obstetrical service on Feb. 6, 1940, approximately one week before her expected date of confinement, because of vomiting of blood and passage of tarry stools for twentyfour hours. The first pregnancy had been uncomplicated and resulted in the spontaneous term delivery of a normal female infant, 3,220 gm., three years prior to the present pregnancy. The patient stated that during the latter months of her pregnancy she had vague attacks of indigestion, which she described as ''heartburn," and that these often occurred during the night, following the ingestion of food before retiring. However, this symptom had been present during her first pregnancy and was similar to the complaints of a large percentage of pregnant women. For several days prior to admission she haa ha.d occasional dizzy spells and was easily fatigued. The pregnancy had otherwise been uncomplicated. The \Vassermann test was negative. The weight gain was 20 pounds (from 114 to 134 pounds), and the blood pressure ranged petween 110 and 120 systolic over 70 to 80 aiastolic. The urine on all occasions was free from albumin and sugar. There had been no previous hematerne~i~ or tarry stools. She gave a history of having had some gastrointestinal complaints in Ul35. A gastrointestinal series, done at that time, showed a ptosis of the stomach and colon.
•
154
GREELEY AND STCBENBORD:
GASTRIC HEMORRHAGE IN PREGNA!\I"CY
155
On admission at 4:00 P.M., the patient was rather pale but in good condition. The pulse was rapid but of good quality. The examination of the chest was essen· tially negative, the heart was not enlarged, rhythm regular, and blood pressure 125/85. She complained of nausea on palpation of the abdomen. The red blood count was 3,020,000; hemoglobin 72 per cent Sahli. The urine showed no albumin or sugar, and the microscopic examination was negative. At 6:15 P.l'.L she vomited 700 c.c. of partially clotte•l blood and complained of faintness and dizziness. The blood pressure fell to !l6/50 ; pulse was 130 and of fair quality. R-ectal examination revealed tarry stool on the examining finger. She was given 0.015 gm. of morphine sulphate every four hours by hypo•lermic injee· tions with nothing by mouth. In addition to thi", she was given a transfusion of 400 c.e. of citrated blood. Ice bags were applied to the upper abdomen. At 8:00 P.M. she vomited 300 c.c. more of older·appearing blood dotH, but there was no appreciable change in her condition at this time. The following morning the patient seeme•l more comfortable; the pulse was of good quality but was still rapid, 130 per minute; blood pressure 94/60; the hemoglobin was 62 per cent. No additional vomiting occurred. She was given another transfusion of 350 c.c. of eitrated blood. The fetal heart was not heard after 6 A.M., and fetal movements were not felt after this time. Labor started spontaneously at ll :00 A.M. 'fhe membranes rup· tured at 9:05 A.M. The contractions at this time were mild, coming every seven to ten minutes apart. At 12 NOON the uterus was noted to be tetanically contracted but not tender; only the lower uterine segment relaxed between pains. At this time we thought that we were .dealing with a premature separation of the placenta. The cervix at this time was effaced and 2 to 3 em. dilated, with the head at the spines in an L. 0. A. position. Labor progressed rapidly and at 2 P.M. the patient was delivered by low forceps under light gas oxygen anesthesia. The baby was a deadborn, not macerated, male infant, weighing 2,530 gm. The placenta separated three minutes later and was expressed from the vagina by Schultze's mechanism. Gross and microscopic examination of the placenta revealed no evidence of premature separation or any other abnormality. 'l'he total blood loss was estimated at 50 c.c. Five hundred cubic eentimeters of 5 per cent glucose were given following delivery, and the patient was returned to her bed in good condition. At !l :00 P.M. another 500 c.c. of glucose were given. The patient was placed on a Sippy regime along with vitamin K by injection and ~itamin C by mouth. Infusions of 500 c.c. of 5 per cent glucose were given on the first two post-partum days. There was no further hematemesis and the stools were negative for occult blood. Four cubic centimeters of iron anunonium citrate (50 per cent solution) were given three times a day. On February 28, a gastrointestinal series revealed visceroptosis with no evidence of peptic ulcer or other pathology. Her .diet was gradually increased, and she im· proved rapidly under con~
On admission to the hospital it was felt that the patient had either a bleeding peptic ulcer or a ruptured varix. In view of the neg- with subsequent x·ray examinations failing to reveal any defects. Hemorrhage is merely an incident and may bear little relation to the size, the site, or even the
156
AMERICA::1 JOURNAL OF OBS'l'ETRICS AND GYNECOLOGY
presence of an ulcer or erode.d area. Hernatemesis may be associateu with a variety of conditions, and it may be very difficult or even impossible to demonstrate the etiologic factor. We are at a loss to explain any cause for the intrauterine death of the fetus and the tetanie state of the uterus during labor. Strangely enough, the case reported by Preiss produced the same result. We might postulate, tentatively, that severe gastrointestinal bleeding might affect the uterine circulation sufficiently to produce the syndrome characterized by death of the fetus and tetanic contraction of the uterus. Yet the same result is not associated with hemorrhage .from placenta previa. REFERENCES
(1) Stwrrock, W. D.: Brit. M. J. 1: 218, 1913. (2) Preiss, E.: Gynack, Rundschau 1: 725, 1907. (3) BaJfO'Ur, D. C.: Collected Papers, Mayo Clinic 14: 53, 1922. (4) Euste1'11WIJI., G. B.: St. Paul M. J. 15: 587, 1913. (5) Bo.J,fowr, D. C.: J. A. M. A. 73: 571, 1919. (6) White, W. H.: Lancet 2: 1189, 1906.
WATERS CESAREAN SECTION IN A PATIENT WITH GAS BACILI~US AND MIXED INFECTION JoHN FALLON,
M.D.,
AND Ju>I'E:s
T.
BROSNAN,
M.D.,
WoRCESTER,
:MAss.
(From the Fallon Clinic)
HE Waters section for infected patients may be an outstanding contribution to obstetric surgery. The original communication! establishes its anatomic supe· riority over similar operations and, with a series of 60 cases without maternal death, suggests technical safety. But its behavior in the clinical test of actual infection still is unproven: only 1 of Waters' 60 patients is recorded as infected, although 14 had preoperative fever. And we have found no other papers on the operation. Nowadays infections serious enough to offer it a stringent test are unusual.
T
CASE REPORT
A 32-year-old pr1m1para (Clinic No. 14711) had dependent edema (Grade 2), albuminuria (Grade 4), evidences of severe pyelonephritis, and blood pressure of 155/82 with, incidentally, a history of systolic pressure over 200 for some weeks before. We saw her first after seventy-two hours of satisfactory labor pains, when, despite the absence of bony disproportion and with no history of cervical disease or operation, the cervix still was only one finger dilated. Several vaginal examinations and attempts at manual and instrumental dilatation had been made since rupture of the membranes, which had preceded by eight hours the onset of pains. There was a thin, foul vaginal discharge. The temperature was 100.2" F., the weak pulse 120 and the leucocyte count 20,500. After four hours' rest by morphine, during which sulfanilamide and parenteral Jluids were begun, a Waters section under spinal anesthesia and a transfusion were done. It was recorded that opening the uterus released ''a stench like that of appendiceal peritonitis, not at operation but at autopsy." The baby died the next day, and post-mortem examination showed general sepsis of two or three days' estimated duration. The mother's convalescence was stormy, with uremia, serum sickness, metastatic infections, and septicemia. Despite a large subperitoneal abscess, evacuated by rectum on the thirteenth day, there was no evidence of peritonitis, and she was discharged relieved on the thirty-sixth day. The organisms recovered from the uterine cavity were hemolytic staphylococci and streptococci, various bacilli, and Clostridiu-m welchii. The chief postoperative treatments were double-time Elliott therapy, sulfanilamide, and, for the gas bacillus, roentgen therapy and antitoxin.
v.
GREELEY, M.D., AND WILLIAM D. STUBENBORD, M.D., NEW YORK, N. Y.
(From the New York Hospital
11/Ml
Cornell University and Mediool College)
following ease is being reported because of the rare occurrence of severe T HE gastric hemorrhage occurring in a pregnant woman at term. Only two reports could be found in the literature on similar types of cases, and no mention of the subject could be found in any of the standard textbooks on obstetrics. Sturrock,l in 1913, reported a case of gastric hemorrhage occurring at the time of delivery, but this case was m no way comparable to the one we are reporting. Subsequent studies were not done and no adequate explanation was given for its cause. Preiss,z in 1907, reported the case of a woman who had a similar accident in her second and third pregnancies. Her first pregnancy was entirely normal. The second pregnancy, fifteen months later, and the third, three years after the second, were complicated by the occurrence of sudden severe gastrointestinal hemorrhages evidenced by vomiting of blood, passage of bloody stools, and shock. In both pregnancies, the bleeding occurred about two weeks before the expected date of confinement and was not associated with any previous gastrointestinal symptoms. In both instances, the onset of labor and delivery were spontaneous within twenty-four hours after the bleeding. The birth of normal, deadborn, male infants was the result in both pregnancies; the fetal hearts were lost during labor without any apparent cause. The puerperiums were normal in both pregnancies, and in the second pregnancy no special diet was given. The author discusses the possible causes of the bleeding and comes to the conclusion that it was due to a ruptured gastric varix produced by the mechanical stimulation of solid food. Contrary to our experience, both Sturrock and Preiss make the statement that gastrointestinal hemorrhage during pregnancy i~ not an uncommon complication. In going over the records of the New York Hospital and the Berwind Maternity Clinic, no such complication occurred during labor in 27,942 deliveries. There was, however, one caFe of moderately severe hematemesis in a five months pregnant woman, who improved on bed rest and diet and went to term without further complications. Our patient was a 31-year-old gravida ii, para i, who was admitted to the obstetrical service on Feb. 6, 1940, approximately one week before her expected date of confinement, because of vomiting of blood and passage of tarry stools for twentyfour hours. The first pregnancy had been uncomplicated and resulted in the spontaneous term delivery of a normal female infant, 3,220 gm., three years prior to the present pregnancy. The patient stated that during the latter months of her pregnancy she had vague attacks of indigestion, which she described as ''heartburn," and that these often occurred during the night, following the ingestion of food before retiring. However, this symptom had been present during her first pregnancy and was similar to the complaints of a large percentage of pregnant women. For several days prior to admission she haa ha.d occasional dizzy spells and was easily fatigued. The pregnancy had otherwise been uncomplicated. The \Vassermann test was negative. The weight gain was 20 pounds (from 114 to 134 pounds), and the blood pressure ranged petween 110 and 120 systolic over 70 to 80 aiastolic. The urine on all occasions was free from albumin and sugar. There had been no previous hematerne~i~ or tarry stools. She gave a history of having had some gastrointestinal complaints in Ul35. A gastrointestinal series, done at that time, showed a ptosis of the stomach and colon.
•
154
GREELEY AND STCBENBORD:
GASTRIC HEMORRHAGE IN PREGNA!\I"CY
155
On admission at 4:00 P.M., the patient was rather pale but in good condition. The pulse was rapid but of good quality. The examination of the chest was essen· tially negative, the heart was not enlarged, rhythm regular, and blood pressure 125/85. She complained of nausea on palpation of the abdomen. The red blood count was 3,020,000; hemoglobin 72 per cent Sahli. The urine showed no albumin or sugar, and the microscopic examination was negative. At 6:15 P.l'.L she vomited 700 c.c. of partially clotte•l blood and complained of faintness and dizziness. The blood pressure fell to !l6/50 ; pulse was 130 and of fair quality. R-ectal examination revealed tarry stool on the examining finger. She was given 0.015 gm. of morphine sulphate every four hours by hypo•lermic injee· tions with nothing by mouth. In addition to thi", she was given a transfusion of 400 c.e. of citrated blood. Ice bags were applied to the upper abdomen. At 8:00 P.M. she vomited 300 c.c. more of older·appearing blood dotH, but there was no appreciable change in her condition at this time. The following morning the patient seeme•l more comfortable; the pulse was of good quality but was still rapid, 130 per minute; blood pressure 94/60; the hemoglobin was 62 per cent. No additional vomiting occurred. She was given another transfusion of 350 c.c. of eitrated blood. The fetal heart was not heard after 6 A.M., and fetal movements were not felt after this time. Labor started spontaneously at ll :00 A.M. 'fhe membranes rup· tured at 9:05 A.M. The contractions at this time were mild, coming every seven to ten minutes apart. At 12 NOON the uterus was noted to be tetanically contracted but not tender; only the lower uterine segment relaxed between pains. At this time we thought that we were .dealing with a premature separation of the placenta. The cervix at this time was effaced and 2 to 3 em. dilated, with the head at the spines in an L. 0. A. position. Labor progressed rapidly and at 2 P.M. the patient was delivered by low forceps under light gas oxygen anesthesia. The baby was a deadborn, not macerated, male infant, weighing 2,530 gm. The placenta separated three minutes later and was expressed from the vagina by Schultze's mechanism. Gross and microscopic examination of the placenta revealed no evidence of premature separation or any other abnormality. 'l'he total blood loss was estimated at 50 c.c. Five hundred cubic eentimeters of 5 per cent glucose were given following delivery, and the patient was returned to her bed in good condition. At !l :00 P.M. another 500 c.c. of glucose were given. The patient was placed on a Sippy regime along with vitamin K by injection and ~itamin C by mouth. Infusions of 500 c.c. of 5 per cent glucose were given on the first two post-partum days. There was no further hematemesis and the stools were negative for occult blood. Four cubic centimeters of iron anunonium citrate (50 per cent solution) were given three times a day. On February 28, a gastrointestinal series revealed visceroptosis with no evidence of peptic ulcer or other pathology. Her .diet was gradually increased, and she im· proved rapidly under con~
On admission to the hospital it was felt that the patient had either a bleeding peptic ulcer or a ruptured varix. In view of the neg-
156
AMERICA::1 JOURNAL OF OBS'l'ETRICS AND GYNECOLOGY
presence of an ulcer or erode.d area. Hernatemesis may be associateu with a variety of conditions, and it may be very difficult or even impossible to demonstrate the etiologic factor. We are at a loss to explain any cause for the intrauterine death of the fetus and the tetanie state of the uterus during labor. Strangely enough, the case reported by Preiss produced the same result. We might postulate, tentatively, that severe gastrointestinal bleeding might affect the uterine circulation sufficiently to produce the syndrome characterized by death of the fetus and tetanic contraction of the uterus. Yet the same result is not associated with hemorrhage .from placenta previa. REFERENCES
(1) Stwrrock, W. D.: Brit. M. J. 1: 218, 1913. (2) Preiss, E.: Gynack, Rundschau 1: 725, 1907. (3) BaJfO'Ur, D. C.: Collected Papers, Mayo Clinic 14: 53, 1922. (4) Euste1'11WIJI., G. B.: St. Paul M. J. 15: 587, 1913. (5) Bo.J,fowr, D. C.: J. A. M. A. 73: 571, 1919. (6) White, W. H.: Lancet 2: 1189, 1906.
WATERS CESAREAN SECTION IN A PATIENT WITH GAS BACILI~US AND MIXED INFECTION JoHN FALLON,
M.D.,
AND Ju>I'E:s
T.
BROSNAN,
M.D.,
WoRCESTER,
:MAss.
(From the Fallon Clinic)
HE Waters section for infected patients may be an outstanding contribution to obstetric surgery. The original communication! establishes its anatomic supe· riority over similar operations and, with a series of 60 cases without maternal death, suggests technical safety. But its behavior in the clinical test of actual infection still is unproven: only 1 of Waters' 60 patients is recorded as infected, although 14 had preoperative fever. And we have found no other papers on the operation. Nowadays infections serious enough to offer it a stringent test are unusual.
T
CASE REPORT
A 32-year-old pr1m1para (Clinic No. 14711) had dependent edema (Grade 2), albuminuria (Grade 4), evidences of severe pyelonephritis, and blood pressure of 155/82 with, incidentally, a history of systolic pressure over 200 for some weeks before. We saw her first after seventy-two hours of satisfactory labor pains, when, despite the absence of bony disproportion and with no history of cervical disease or operation, the cervix still was only one finger dilated. Several vaginal examinations and attempts at manual and instrumental dilatation had been made since rupture of the membranes, which had preceded by eight hours the onset of pains. There was a thin, foul vaginal discharge. The temperature was 100.2" F., the weak pulse 120 and the leucocyte count 20,500. After four hours' rest by morphine, during which sulfanilamide and parenteral Jluids were begun, a Waters section under spinal anesthesia and a transfusion were done. It was recorded that opening the uterus released ''a stench like that of appendiceal peritonitis, not at operation but at autopsy." The baby died the next day, and post-mortem examination showed general sepsis of two or three days' estimated duration. The mother's convalescence was stormy, with uremia, serum sickness, metastatic infections, and septicemia. Despite a large subperitoneal abscess, evacuated by rectum on the thirteenth day, there was no evidence of peritonitis, and she was discharged relieved on the thirty-sixth day. The organisms recovered from the uterine cavity were hemolytic staphylococci and streptococci, various bacilli, and Clostridiu-m welchii. The chief postoperative treatments were double-time Elliott therapy, sulfanilamide, and, for the gas bacillus, roentgen therapy and antitoxin.