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Ruptured pregnancy in the closed rudimentary horn of a bicornate uterus
GORDON:
RPPTURED PREGNANCY IX CT.Ol-'1<:[) H1'Jlll\1E:..(TAHT HOHJ\
~~/!)
indivir!ual droplets were larger. These <'.l'lls stainP
In view of the absence of both sug·ar anr! larger quantitit>s of protrin it \Va~ felt that the possibility of the fluid's lJPing a tran~wlat<> wa~ ruler! out. Walther reports the findinf_;- of Ppitht>lial r•t>llH and fat droplPts in th!• tluid in his case hut records no intrrwellular lipoid !lropl<'t~. I wish to express my sincere appreciation to Drs . .J. M. H. Rowland and L. H. Douglass of the Department of Obst<'tri<'s: Drs. H. R. SpenC'er an
RUPTURED PREGNANCY IN THE CLOSED RUDil\TEN'J'AH.Y HORN OF A BICORNATE liTERFS ExTERNAL .MIGRATION oF THE SPERMATAZOON; URINARY SuPPREsswx F'OLLOWING TRANSJ'o'USION CHARLES
A.
GORDON,
l\I.D., F.A.C.S.,
BROOKLYN,
X. Y.
THIS ease of pregnancy in the closed aceessory or rudimentary horn of a. bicornate uterus is reported because of its rarity, and the nature of tlw transfuswn death, and to record a definite instance of t>xternnl o1· peritoneal migration of the sperma~ tazoon. M. S., German, aged twenty-eight, married eleven ntonth:l, was admitted to f:.:t. Catherine's Hospital on March 18, 1933, romplaining of ahrlominal pain. Her last menstrual period occurred on Oct. 12, 1932, with a preYiously rPgular 28/4 menstrual eycle without pain or diseomfort at :my time. She had sought no prenatal care in this, lH•r first, pregnarwy, and had b]t bettl'r the next day but stayer! in bed. The next day, however, for(V·Pigltt hours aftn the first pain, she felt terrific pain in the abdomen and fainted, falling so heavily against the bath~ room door, that she sustained a wry severe t'Ontusion of the <"he!'k and chin, where a wide area of E>cehymosis and a. hematoma were prt'Rtmt. She was a well-developed young woman, very pal(', with lips, eonjunctival' and mucous membranes almost white, dry tongue, pulse 120, small and of poor quality. Her skin was cold. Heart sounds were of poor nmseular quality. Blood pressure was 120/65; temperature, 99.3; respiration, 34; H. B.C., 1,9i)0,00ll; W.B.C., 14,7fHJ; polymorphonuclears, 87; Hg, 36 per eent. Urim• was negativP. The abdomen was generally rigid, with marked peritoneal rebound pain, shifting dullness in the ftanks, and a firm, SOI!lewhat tender mass thought to be utPrus, hut all to the left of the median line, E>xt<•nding J em. above the umbili('US. Fetal h<'art l'Ould not be heard. The ct>rvix was soft, continuous with thP maRs felt abdominall~·, and there was no history or evidence of vaginal bkPding. A diagnosis of ruptured cornual pregnancy was made, and laparotomy undPr procaine infiltration and gas oxygen anesthesia presented no diffi<·ulties. The time of operation waR twenty~one minutes. Through a mi
280
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
which was turned inside out through a rent 3% inches long, low on its posterior surface. Another uterus about the same size, 3 months' gestation, with normal tube and ovary attached, was seen to the right. After extraction of the fetus, placenta, and membranes, the ruptured uterus was removed supracervically with the left tube and ovary, which showed the corpus luteum of pregnancy, cutting through a bridge about l)ne and one-half inches long and one inch wide which tied it to the other uterus; the abdomen was closed in layers. Operation was preceded by transfusion of 320 c.c. of whole blood, Scannell method, and followed by 520 c.c. of whole blood given the same way. Cross agglutination of dl)nor and recipient showed compatible blood, but grouping was not done. No immediate reaction of any kind was noted during either transfusion. She stood the operation well, and returned to the ward in fairly good condition, but restless. Veniclysis was begun through a cannula which had been left in the vein. She appeared to be better the next day though skin and sclerae showed orangered jaundice, and only a few drops of urine had been obtained by catheter eighteen hours after operation. During the next seven days, she was catheterized once daily,
Rlf.HT
.,.
T\111£
Fig.
I.-Bicornate uterus with rudimentary horn (ruptured).
obtaining nothing or as much as 8 ounces, a total of 29 ounces for this whole period. Blood pressure rose to 150/78. She vomited repeatedly large amounts of brown or black fluid which contained blood. Slight vaginal bleeding began on the day after operation and continued for five days. There was no edema. She remained conscious, though drowsy and apathetic, until she died Qn the twenty-ninth, eleven days after operation. On the last twl) days she had voided 30 ounces of urine each day, and her blood pressure was 168/90 . Treatment consisted of gastric lavage, glucose veniclysis and drip, saline clysis, colonies and twQ hot packs. Except for blood on two occasions) the urine showed only a heavy trace of albumin and an occasional hyaline cast in several postoperative examinations. The blood on the twenty-fifth showed: Urea nitrogen 161 mg. per 100 c.c., sugar 150 mg., creatinine 4 mg.; on the twenty-seventh, urea nitrogen 161 mg., sugar 140 mg., creatinine 4 mg.; on the twenty-ninth, urea nitrogen 224 mg., sugar 180 mg., creatinine 12.5 mg. Blood counts showed: On the twenty-third, R.B.C. 2,400,000, W.B.C. 18,400, polymorphonuelears 81 per cent, Hg, 41 per cent; on the twenty-ninth, R.B.C. 2,620,000, W.B.C. 31,000, polymorpho.nuclears 84 per cent, Hg 51 per cent; moderate achromia, poikilocytosis, anisocytosis, and polychromatophilia were always present.
GORDON:
RUPTURED PREGNANCY IN CLOSED RUDIMENTARY HORN
2RJ
NECROPSY AND PATHOLOGIC REPORT
Necropsy consent was limited to opening the incision which was found well healed. The spleen and liver were not seen, but appeared normal on palpation. The stomach was dilated and rllled with fluid. The large and small intestine were normal. There was no free fluid, and no evidence of peritoniti:l. The remaining uterus was twice normal size, its cavity communicating with a normal cervix and a normal tube and ovary. The well-healed muscular stump of the excised uterus was attached to this uterus just above the 13ervix by a connecting bridge terminating in two folds of peritoneum separated by a :small amount of areolar tissue. Obviously there could be no communication with the other uterus or its cervix, and none could be demonstrated. The rudimentary horn showed a wall 3 em. thick except below the line of rupture where it was very thin. Typical corpus luteum of pregnancy, one-fourth the size of the ovary, was present in the left ovary. The kidneys were pale and large, with easily stripped <~apsules and soft gray cortex; the markinga;,of the medulla were accentuated. Th£1 right kidney was 1112 times normal size with a normal ureter which was followed to the bladder. The left kidney was 3 times normal size and appeared to be two kidneys fused with a double pelvis and two ureters with two bladder orifices, patent throughout. Microscopically the kidneys were adematous with accumulations of small round cells between the tubules. The glomeruli were swollen, with dilated capsules. The collecting tubules showed granular degeneration and masses of brown pigment (hemoglobin) more abundant and more deeply staining in their distal portions. COMMENT
The corpus luteum of pregnancy was found in the left ovary. The closed rudi· mentary horn of the bicornate uterus was on the left side, and clearly not in communication with the cervix. Fertilization was possible only by external migration of the spermatazoon. Hartman believes that movements of tho viscera may move the spermatazoon about until chance brings it in contact with the infundibulum. The clinical significance of developmental duplication of the uterus is obvious. In the early months, diagnosis of pregnancy in a rudimentary horn is possible, for the diagnosis was made in 20 per cent of Kehrer's 84 cases collected in 1900. Whether diagnosis is made by rectal palpation of the connecting band, or by feeling the round ligament distal to the mass instead of proximal as in tubal pregnancy, for practical purposes diagnosis must depend upon 0bservatio11 of a tumor correspond· ing to the duration of pregnancy next to an only slightly e:nla.rged uterus. Urinary suppression as a delayed reaction to transfusion is probably not rare. In 1931, James Bordley reported three cases, and gathered fourteen more from the literature of transfusion since the recognition of blood grOUIJS. In an excellent and thorough analysis of these cases he showed that in not a single case was there con· elusive evidence that the bloods of donor and recipient we:re compatible, although he was aware that Ottenberg and Johnson described an incompatible type of reaction occurring even when donor and recipient were of the same blood group. The method of transfusion was unimportant. Tl1e amount of blood injeeted was significant; no patient receiving less than 340 c.c. died, and none receiving more than 540 c.c. recovered. Oliguria, vomiting and uremia were outstanding symptoms of the delayed reaction. The renal lesion was an unusual one yet always the same, and very similar to the lesion found in this case. Bordley offers four possible explanations of the mechanism of the kidney damage: (1) Mechanical blockage of tubules, (2) anaphylactic shock, (3) metabolic disturb·
282
AMERICAN JOURNAL OF OBS'I''WrRICR AND GYNECOLOGY
anee due to loss of chlorides following p<>r~istt'nt vomiting, ( 4) toxic substances in the ineompatible blood. Johnson and Conway, in August, 1933, reported three similar eases. In one of their ~ases, however, cross agglutination and blood grouping were done, and repeated after transfusion; no incompatibility could ht' dl"monstrated. SUMMARY
1. A case of pregnancy in the closed rudimentary accessory horn of a bicornate uterus is reported. Rupture with massive intraperitonea1 hemorrhage, occurred in thE' fifth month and was preceded by partial rupture forty-eight hours before. 2. Fertilization was effected by external migration of the spermatazoon. 3. Death was due to a delayed transfusion reaction characterized by oliguria, vomiting and the uremic snydrome, and probably caused by the injection of incom· patible blood, although eross agglutination had seemed to show no incompatibility.
(1) Beol.:mamn: Ztschr. f. Geburtsh. u. Gyniik, 68: 600, 1911, 978, 1904. (2) Bordley, Jas. III: Arch. Int. Med. 47: 288, 1931. (3) Johnron (IJn(J Conwaty: AM • •T. 0BST. & GYNEG. 26: 255, 1933. ( 4) Smith, F. R.: AM. J. 0BST. & GYNEC. 22: 714, 1931. (5) Die Nebenhorn Schwangersclmft, Handbuch dt?r Geburtshiilfe, Wiesbaden, V. Winckels 2: 978, 1904. 256
JEFFERSON AVENUE.
VAGINITIS EMPHYSEMATOSA
C. J.
MARSHALL,
M.D.,
AND
v. w.
BERGSTROM,
M.D.,
BINGHAMTON,
N. Y.
(Fwm the Departments of Materwity and P.athology of the Bin_qhamton City Hospital and the .Kilmtr Pathological La-boratory) emphy·
]877 Zweifel gave the name of "vaginitis emphysematosa" or "colpitis INsematosa'' to inflammation of the vagina occurring· most often dming pregnancy
and eharacterized by eollections of gas in the mucosa which caused blehlike elevations. On analysis he believed the gas to be trimethylamin. Many observers termed this di~ease '' colpohyperplasia cystica,'' whieh is probably a misnomeJ·, as the gas present has no well-defined walls or boundaries except as it may occasionally he con· tained in the lymph vessels. Jackson and Wright, Heaney and others have reported cases of this diseaRe whkh followed hysterectmny. Hugier in 1847 probably was the 'l'here are ve1y few complete descriptions in the fir~t to describe thi.~ condition. English or American literature, possibly because this type of vaginiti$ has very little clinical significance. In the German literature are many exhaustive reports, the most complete and accurate being that of Nagashima, whose work, however, was based on n study of material procured at autopsy and £rom museum specimens. The practitioner who is not acquainted with the gross pathology of this vaginitis may be perplexed wh<>n he first discovers it, !mel he will he astonished when he tries to perform a biopsy on the vagina only to have thesf' apparent "nodules" break likE' so many toy balloon~. We wish to report the following C1SE' of vaginitis emph,vsematosa as our findings differ slightly from those reported iu the literature: Mrs. M. K., aged forty-two, was bom in Lithuania in 1889. She had two children, both living and well. The patient was admitted to the hospital on Sept. 21, 1931,
RPPTURED PREGNANCY IX CT.Ol-'1<:[) H1'Jlll\1E:..(TAHT HOHJ\
~~/!)
indivir!ual droplets were larger. These <'.l'lls stainP
In view of the absence of both sug·ar anr! larger quantitit>s of protrin it \Va~ felt that the possibility of the fluid's lJPing a tran~wlat<> wa~ ruler! out. Walther reports the findinf_;- of Ppitht>lial r•t>llH and fat droplPts in th!• tluid in his case hut records no intrrwellular lipoid !lropl<'t~. I wish to express my sincere appreciation to Drs . .J. M. H. Rowland and L. H. Douglass of the Department of Obst<'tri<'s: Drs. H. R. SpenC'er an
RUPTURED PREGNANCY IN THE CLOSED RUDil\TEN'J'AH.Y HORN OF A BICORNATE liTERFS ExTERNAL .MIGRATION oF THE SPERMATAZOON; URINARY SuPPREsswx F'OLLOWING TRANSJ'o'USION CHARLES
A.
GORDON,
l\I.D., F.A.C.S.,
BROOKLYN,
X. Y.
THIS ease of pregnancy in the closed aceessory or rudimentary horn of a. bicornate uterus is reported because of its rarity, and the nature of tlw transfuswn death, and to record a definite instance of t>xternnl o1· peritoneal migration of the sperma~ tazoon. M. S., German, aged twenty-eight, married eleven ntonth:l, was admitted to f:.:t. Catherine's Hospital on March 18, 1933, romplaining of ahrlominal pain. Her last menstrual period occurred on Oct. 12, 1932, with a preYiously rPgular 28/4 menstrual eycle without pain or diseomfort at :my time. She had sought no prenatal care in this, lH•r first, pregnarwy, and had b
280
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
which was turned inside out through a rent 3% inches long, low on its posterior surface. Another uterus about the same size, 3 months' gestation, with normal tube and ovary attached, was seen to the right. After extraction of the fetus, placenta, and membranes, the ruptured uterus was removed supracervically with the left tube and ovary, which showed the corpus luteum of pregnancy, cutting through a bridge about l)ne and one-half inches long and one inch wide which tied it to the other uterus; the abdomen was closed in layers. Operation was preceded by transfusion of 320 c.c. of whole blood, Scannell method, and followed by 520 c.c. of whole blood given the same way. Cross agglutination of dl)nor and recipient showed compatible blood, but grouping was not done. No immediate reaction of any kind was noted during either transfusion. She stood the operation well, and returned to the ward in fairly good condition, but restless. Veniclysis was begun through a cannula which had been left in the vein. She appeared to be better the next day though skin and sclerae showed orangered jaundice, and only a few drops of urine had been obtained by catheter eighteen hours after operation. During the next seven days, she was catheterized once daily,
Rlf.HT
.,.
T\111£
Fig.
I.-Bicornate uterus with rudimentary horn (ruptured).
obtaining nothing or as much as 8 ounces, a total of 29 ounces for this whole period. Blood pressure rose to 150/78. She vomited repeatedly large amounts of brown or black fluid which contained blood. Slight vaginal bleeding began on the day after operation and continued for five days. There was no edema. She remained conscious, though drowsy and apathetic, until she died Qn the twenty-ninth, eleven days after operation. On the last twl) days she had voided 30 ounces of urine each day, and her blood pressure was 168/90 . Treatment consisted of gastric lavage, glucose veniclysis and drip, saline clysis, colonies and twQ hot packs. Except for blood on two occasions) the urine showed only a heavy trace of albumin and an occasional hyaline cast in several postoperative examinations. The blood on the twenty-fifth showed: Urea nitrogen 161 mg. per 100 c.c., sugar 150 mg., creatinine 4 mg.; on the twenty-seventh, urea nitrogen 161 mg., sugar 140 mg., creatinine 4 mg.; on the twenty-ninth, urea nitrogen 224 mg., sugar 180 mg., creatinine 12.5 mg. Blood counts showed: On the twenty-third, R.B.C. 2,400,000, W.B.C. 18,400, polymorphonuelears 81 per cent, Hg, 41 per cent; on the twenty-ninth, R.B.C. 2,620,000, W.B.C. 31,000, polymorpho.nuclears 84 per cent, Hg 51 per cent; moderate achromia, poikilocytosis, anisocytosis, and polychromatophilia were always present.
GORDON:
RUPTURED PREGNANCY IN CLOSED RUDIMENTARY HORN
2RJ
NECROPSY AND PATHOLOGIC REPORT
Necropsy consent was limited to opening the incision which was found well healed. The spleen and liver were not seen, but appeared normal on palpation. The stomach was dilated and rllled with fluid. The large and small intestine were normal. There was no free fluid, and no evidence of peritoniti:l. The remaining uterus was twice normal size, its cavity communicating with a normal cervix and a normal tube and ovary. The well-healed muscular stump of the excised uterus was attached to this uterus just above the 13ervix by a connecting bridge terminating in two folds of peritoneum separated by a :small amount of areolar tissue. Obviously there could be no communication with the other uterus or its cervix, and none could be demonstrated. The rudimentary horn showed a wall 3 em. thick except below the line of rupture where it was very thin. Typical corpus luteum of pregnancy, one-fourth the size of the ovary, was present in the left ovary. The kidneys were pale and large, with easily stripped <~apsules and soft gray cortex; the markinga;,of the medulla were accentuated. Th£1 right kidney was 1112 times normal size with a normal ureter which was followed to the bladder. The left kidney was 3 times normal size and appeared to be two kidneys fused with a double pelvis and two ureters with two bladder orifices, patent throughout. Microscopically the kidneys were adematous with accumulations of small round cells between the tubules. The glomeruli were swollen, with dilated capsules. The collecting tubules showed granular degeneration and masses of brown pigment (hemoglobin) more abundant and more deeply staining in their distal portions. COMMENT
The corpus luteum of pregnancy was found in the left ovary. The closed rudi· mentary horn of the bicornate uterus was on the left side, and clearly not in communication with the cervix. Fertilization was possible only by external migration of the spermatazoon. Hartman believes that movements of tho viscera may move the spermatazoon about until chance brings it in contact with the infundibulum. The clinical significance of developmental duplication of the uterus is obvious. In the early months, diagnosis of pregnancy in a rudimentary horn is possible, for the diagnosis was made in 20 per cent of Kehrer's 84 cases collected in 1900. Whether diagnosis is made by rectal palpation of the connecting band, or by feeling the round ligament distal to the mass instead of proximal as in tubal pregnancy, for practical purposes diagnosis must depend upon 0bservatio11 of a tumor correspond· ing to the duration of pregnancy next to an only slightly e:nla.rged uterus. Urinary suppression as a delayed reaction to transfusion is probably not rare. In 1931, James Bordley reported three cases, and gathered fourteen more from the literature of transfusion since the recognition of blood grOUIJS. In an excellent and thorough analysis of these cases he showed that in not a single case was there con· elusive evidence that the bloods of donor and recipient we:re compatible, although he was aware that Ottenberg and Johnson described an incompatible type of reaction occurring even when donor and recipient were of the same blood group. The method of transfusion was unimportant. Tl1e amount of blood injeeted was significant; no patient receiving less than 340 c.c. died, and none receiving more than 540 c.c. recovered. Oliguria, vomiting and uremia were outstanding symptoms of the delayed reaction. The renal lesion was an unusual one yet always the same, and very similar to the lesion found in this case. Bordley offers four possible explanations of the mechanism of the kidney damage: (1) Mechanical blockage of tubules, (2) anaphylactic shock, (3) metabolic disturb·
282
AMERICAN JOURNAL OF OBS'I''WrRICR AND GYNECOLOGY
anee due to loss of chlorides following p<>r~istt'nt vomiting, ( 4) toxic substances in the ineompatible blood. Johnson and Conway, in August, 1933, reported three similar eases. In one of their ~ases, however, cross agglutination and blood grouping were done, and repeated after transfusion; no incompatibility could ht' dl"monstrated. SUMMARY
1. A case of pregnancy in the closed rudimentary accessory horn of a bicornate uterus is reported. Rupture with massive intraperitonea1 hemorrhage, occurred in thE' fifth month and was preceded by partial rupture forty-eight hours before. 2. Fertilization was effected by external migration of the spermatazoon. 3. Death was due to a delayed transfusion reaction characterized by oliguria, vomiting and the uremic snydrome, and probably caused by the injection of incom· patible blood, although eross agglutination had seemed to show no incompatibility.
(1) Beol.:mamn: Ztschr. f. Geburtsh. u. Gyniik, 68: 600, 1911, 978, 1904. (2) Bordley, Jas. III: Arch. Int. Med. 47: 288, 1931. (3) Johnron (IJn(J Conwaty: AM • •T. 0BST. & GYNEG. 26: 255, 1933. ( 4) Smith, F. R.: AM. J. 0BST. & GYNEC. 22: 714, 1931. (5) Die Nebenhorn Schwangersclmft, Handbuch dt?r Geburtshiilfe, Wiesbaden, V. Winckels 2: 978, 1904. 256
JEFFERSON AVENUE.
VAGINITIS EMPHYSEMATOSA
C. J.
MARSHALL,
M.D.,
AND
v. w.
BERGSTROM,
M.D.,
BINGHAMTON,
N. Y.
(Fwm the Departments of Materwity and P.athology of the Bin_qhamton City Hospital and the .Kilmtr Pathological La-boratory) emphy·
]877 Zweifel gave the name of "vaginitis emphysematosa" or "colpitis INsematosa'' to inflammation of the vagina occurring· most often dming pregnancy
and eharacterized by eollections of gas in the mucosa which caused blehlike elevations. On analysis he believed the gas to be trimethylamin. Many observers termed this di~ease '' colpohyperplasia cystica,'' whieh is probably a misnomeJ·, as the gas present has no well-defined walls or boundaries except as it may occasionally he con· tained in the lymph vessels. Jackson and Wright, Heaney and others have reported cases of this diseaRe whkh followed hysterectmny. Hugier in 1847 probably was the 'l'here are ve1y few complete descriptions in the fir~t to describe thi.~ condition. English or American literature, possibly because this type of vaginiti$ has very little clinical significance. In the German literature are many exhaustive reports, the most complete and accurate being that of Nagashima, whose work, however, was based on n study of material procured at autopsy and £rom museum specimens. The practitioner who is not acquainted with the gross pathology of this vaginitis may be perplexed wh<>n he first discovers it, !mel he will he astonished when he tries to perform a biopsy on the vagina only to have thesf' apparent "nodules" break likE' so many toy balloon~. We wish to report the following C1SE' of vaginitis emph,vsematosa as our findings differ slightly from those reported iu the literature: Mrs. M. K., aged forty-two, was bom in Lithuania in 1889. She had two children, both living and well. The patient was admitted to the hospital on Sept. 21, 1931,