Purpura hemorrhagica complicating pregnancy

SZ',lTEI) MEISTISG, OCTOBER 2. I!,,:1 DR.

ISIDORE

plicating

llaxctlmm

wportccl a c*ase of Purpura

Hemorrhagica

Com-

Pregnancy.

A. E., a primipasa, aged twenty-seven years (last menses May 30, 1929, due Maxch 6, 1930) was admitted to the Jewish Hospital of Brooklyn Prlxuar~ 15, 1930 at, 8 A.M. with a histoy of having had continuous cramps since 9 ~.htl. tho night brfore. Membranes were intart: there was no bleeding or staining, ant1 no history of toxic symptoms. Blood pressure at thr time of admission \Vas 115/X0. pulse X4, red blood cells 3,900,000, hemoglobin 60 per cent. I’rinr was not> exominrtl on admission. This patient had been to tllrt prenatal cdlinic t,hree times bcforc~ her admission to the hospital. Condition normal. examination revc:tlr~l a fairly At the time of admission to tllr hospital, ,.Ihdumin:rI tonic uterus, tender to the touch. Fundus measurrd 29 cm. and no fetal tIeart, was heard. Rec+al examination showed the cervix t,o bc well eff:t~rl, a little over ow h diagnosis of ahlntio placrnta with finger dilated, and a vcrtcs well in the llrim. death of thr fetus was made, notwithstanding tlrr normal blood pws~nw, good pulse, and no evidence of bleeding. She continued t,o hare constant abdominal cramps anal ttitx lmlse gradually rose to About 100, but thcb patient looked well clinically and there was no cstc~nal l~lceding. 12 : 30 P.N. it, was accidentally discnrcrcd that the patient Id an erchvmotic area over each rtllterior forearm wl~~re intracutancous inject,ions of some spcc*ial t& material had been made about two hours Ibefore. Tlw hlood prcwurc at. this time was 13Oi8-I and the urine showed a lic~avy cloud of albumin, with man? tlyaline and granular casts. The ecchymotic :~en suggested a blood dpscrasia and a~ inlmctliate blood study mxs made by the Pathological Laborat,ory. WW bleeding time was over t\ro and one-half minutes, coagulation time four minutes, hemoglobin (1181~ j 411 *wr writ. ret1 t~lootl ~11s J,640,WX1, l~lat~elcts 165,000, pol~~r~c~rl~honucl~~ars 91 per rcaut, lymphocytes 9 per cent, clot retrac%ion, none’ aftrr twc,ntT-frlur hours. At 1 P.&l. patient rccei\-csd : grain of tnorphiue. Ilctmecn 1 and 6 P.hl., the pulse eont,inued tll risr until it, rt-ached 140, blood pressure varied from ISI)/ to 140/84. Ttlerx~ was still no evidence of nny external bleeding. The lips were a bluish gray, while the face llad a peculiar grayish color. At this time there was smne hlred~ng front the gums. The uterus was still fairly tonic and the c~~rx+s was only one iingcxr Idilated. The pulse was of rather pool quality. A urea nitrogen done at this tin10 was 16.4. Roth thca Medical Service and the pathologist saw the patient and concurred in the diagnosis of acute glomerular Carrful cIut>stioning of the patic,nt autl her relatives ntphritis with :I toxic purpura. rrT-ealed a rompletcly negatire past and famiI>- histoy. Ait 6 P.M. laI)or was indnrcd by ruI)t,nriirg thr membranes and inscrtjng a ?io. rj 'f'ttr hag WRY expelled at 1 :30 A.X. Voorl~ces bag into tlrcx cc,rvis Tyithout ;+nc~st,hesia. The head was perforated and the baby tlelivcrcd at 2 .4x. TIw placenta was seen at tlic vulva immediately after the infant, and it was followed t)T about 300 c.8. of old I,lood l~rcssuro was 88/N ; pulse blood and several large clots. F~~llowing delirery, As the uterus r~~mained flabby and atonic, it was was rapid and of fair quality. parked at once with gauze soaked in 1~~ercuro~l11.o111c’. There was :, first degrrr laceraThe placpnta showed a large area of tion of the perineum which was not repaired. infarction and thinning out,, covering over half the maternal surfaec, and several blood clots were adherent to tlte thinned out, area. A transfusion of 350 C.C. II~ whole blood was given :ilrout one hour folluwiug deliT--cbry and the patient picked up n&l?. &\t this time she had numerous ecchynoses

BROOKLYN

GYNECOLOGICAL

SOCIETY

153

over the upper and lower extremities. The pulse gradually became fuller and slower and her general condition semed to be improved. Before delivery, hemoglobin (Dare) was 40 per cent, and red blood cells 2,200,OOO. Bfter the transfusion, hemoglobin (Dare) was 50 per cent and red blood cells 2,180,OOO. The next morning the blood pressure was 1.02/64, pulse 90-100 and of good quality. Urine showed a heavy cloud of albumin and many casts. The temperature on this day varied from 99” to 100” F., while the pulse fluctuated from 90 to 110. The patient looked very much improved. It is of interest that this patient began to improve immediately after transfusion and continued to do so day by day. 9 second blood study done two days after delivery showed: hemoglobin (Dare) bleeding time seven and one-half minutes, 34 per cent, red blood cells Z,384,000, coagulation time two and one-half minutes, platelets 128,000, white blood cells 7,750, with a normal differential, and clot retraction time normal. A blood chemistry showed normal figures, while the Kahn a.nd Wassermann tests’ were both negative. On the third day postpartum, a second transfusion of 300 C.C. of blood was given On this day the urine showed only a faint trace of to combat the secondary anemia. The next day and every day after that the urine albumin and an occasiona, cast. The blood pressure showed either no albumin or a very faint trace and no casts. varied from 108/60 to 118/68. Examination of the eyegrounds four days after delivery showed the discs to be There was some connective t,issue deblurred in outline, especially on the right side. posits around the blood vessels in the discs, hut no hemorrhages or exudates were made out. For the first six days postpartum, the temperature fluctuated between 99” and The only puerperal complication was a 101” and the pulse between 90 and 100. After that the temperature and lochiometra which cleared up after a few days. pulse were perfectly normal. At no time was the spleen felt nor were any petechiae noted. The ecchymoses noticed before delivery cleared up within forty-eight. hours. The patient, was out of bed on the eleventh day and went home at the end of the second week. il blood study done one day before discharge showed: hemoglobin (Dare) 42 per cent, red blood cells 3,600,000, bleeding time two minutes, coagulation time three minutes, platelets 400,000, white blood cells 13,000, with 68 per cent polymorphonuclears. The patient was seen six weeks lat.er, on March 29, 1930. Careful questioning and examinations showed that there had been no bleeding from any of the mucous membranes, and no petechiae or ecchymoses had appeared. The patient’s color was good, the urine was completely negative, and the blood pressure 11?/70. Spleen could not be made out. Pelvic examination revealed a healed first degree laceration, a slightly lacerated cervix, and a normally placed uterus well involuted. Blood chemistry was normal ; Kahn and Wassermann tests were negative. Blood study showed: hemoglobin (Dare) 70 per crnt, red blood cells 3,500,000, white blood cells 10,000 with a normal differential. Eleeding time normal. Coagulation time normal. Number of platelets normal. Clot retraction normal. We were evidently dealing, in this case, with a latent toxemia of which the ablatio placenta and purpura were only symptoms. The purpura was not primary but toxic and as the toxemia cleared up, the purpura disappeared. DISCUSSION DR. HARRY KOSTER.-It tween the thromboeytopenic treatment must be essentially

seems to me that it is important to distinguish betype and the nontlnomborytopenic type, because the In the true, essential thrombocytopenic type, different.

154

A&tERICAN

JOURKAL

OF ORSTE’I’RIW

ASD

GBNEC’OLOGT

the only treatment of any value in a seriously ill patient, livery. All the other types respond to emptying the uterus which is responsible for the hemorrhagic symptoms. DR.

M. ROSENBERG reported

fied Pomeroy

is splcnectumy plus deor treat,ing the toxicit)

a case of Ectopic Gestation

Following

Modi-

Sterilization.

Patient E. C., 71.hite, agod thirty-four years. was admitted to my service at The Jewish Hospital, on July 03, 1930, lvith a l&tory of rheumat.ir tndocarditis of SWera1 years’ duration complicated by a five weeks’ pregnancy, last menstrual period heing June 13, 1930. Patient has been married sixteen years and has two childrm, the youngest six years old. The first child mas deliverrd by instrument. The patient presented a mitral systolic murmur and t.ender joints throughout. the body. The pelvic floor was rclarcd, a slight eystoccle, was present,, the uterus anteroposrd, somewhat enlarged and soft, the adnesa mere negative. Because of the history of rheumatic endocarditis a therapeutic abortion and sterilization was decided upon. On July 24, 1930, a dilatation and curettage was performed, followed by an anterior colporrhaphy through which was done a modified Pomcrog sterilization ; that is, ligation and resection of a large loop of the cornual end of the tubes followed by electrocauterization of the severed ends of t,he tubes. PaCent made an uneventful recovery and was discharged on August 3, 1930. On December 5, 1930, patient was rcadmit,ted to Dr. Schwartz ‘R service at The Jewish Hospital with the following history : Pnticnt had two regular periods in The October period was delayed a few hugust and September, following operation. days so that latient resorted to medication, and began bleeding on November 10, 1930. The bleeding last,ed about three days. Hoxvever, on November 43, she hegan bleeding again, and on November 29 she experienced a severe sharp pain in the left lower quadrant, the pain Ijeing constant in character and associated lvith sl’otting and painful micturition. Examination revealed marked abdominal tenderness with no rigidity in the left lower quadrant. Vaginal esaminat,ion revealed a firm parous pelvic floor with a well-healed firm anterior wall, a parous soft cervix that xvas tender on motion ; tht: uterus slightI> enlarged, was displaced anteriorly and to the right by a very tender small cystit, mass in the left fornir. Diagnosis of a left tubal pregnancy xas mn11~~. On December 6, 1930, a postvaginal section was performed, and frtse blood ~vas found in the perit,oneal cavity. This was followed hy an immediate laparotomy. h median infraumhilical abdominal incision was made. The abdominal cavity was filled with a moderate amount of hlood and blond clots. The omentum mas found strctc~hcd a.nd intimately adhere& to both cornunl ends of thr uterus at the site of the previous resection of the tubes. The right tube lvas normal and separated from the uterus at its eornual end. The left tube which xas thr seat of an cctopic gestation Iras distended at its proximal end which xvas smooth and distinctly separated from the cornual end of the uterus. The two round ligaments were intact. The omcntum was freed from its adhesions and ligated. The left tube n-as freeti from its adhesions, and a left, salpingcctomy was performed. The ahdomen was closed in layers. The tube was 7 em. long, al,out two-thirtls distended by blond clot 2 cm. in diam cter, attached t,o the wall of the tube. xieroseopically, the tube was the seat of a c-lwtrnic inflammatory ~~OCTSS, contents consisting of blood clot and chorionic villi. From the above case and those others reported in the literature it is evident that tubal ligation wit11 resection is not au eficirut measure to prewnt NWeptiOlL