Ruptured uterus: Peritonitis, operation and recovery

BARRETT Accuracy in pelvic deviates from normal for mother and child

:

GENCSEE

has proved very useful, it accurate when the anatomic

is small, easily points are first

STREET

RUPTURED

UTERUS : PERITONITIS, ANDRECOVERY

RALPH (From

509

UTERUS

mensuration becomes most important when the type of pelvis and the question of how to deliver to secure the best results frequently presents a very difficult problem.

In my hands, this new pelvimeter carried, easily read and surprisingly checked by the examining fingers. 608 EAST

RUPTUR,RD

L.

BARRETT,

the Obstetric

Service

M.D., Nxw of

the

OPERATION

YORK,

EXckerbooker

N. Y. Hospital)

T THE Woman’s Hospital, in the last thirteen years, there have been twelve cases of uterine rupture associated with pregnancy or labor. Eleven of these patients had prompt laparotomy with hysterectomy or repair. All these patients recovered. One patient was treated by tamponade together with transfusion. No 1aParOtOmy was done. This patient died forty-eight hours later of peritonitis and shock.

A

The case which I wish to present illustrates the difficulty in making a diagnosis of It also illustrates uterine rupture postpartum when the lesion is of minor degree. the dangers to which these women are subjected if the diagnosis and treatment are delayed. Mrs. M. spontaneous

Il., aged deliveries

thirty-one of normal

years, white, gravida babies at term.

iii.

She had

had

two

previous

She was admitted to the Knickerbocker Hospital Obstetrical Service Oct. 9, 1935, in the first stage of labor, at full term. Her antepartum period had been entirely normal. Her labor in the Hospital appeared to be uneventful for about eighteen hours, contractions occurring at threeto eight-minute intervals and of moderate severity. Examination on admission indicated a vertex presentation in right occipitoposterior position with the presenting part floating and gradually settling in and fixing in the brim. Sixteen hours after admission to the hospital and about twentytwo hours after onset of labor the membranes ruptured spontaneously. She was e,xamined by the interne at this time, who found the presenting part wedged in the brim in what he considered to be right occipitoposterior position with the cervix fully dilated. The patient continued to have strong uterine contractions for the next two hours but as there seemed to be no progress in the descent of the child, he called an attending obstetrician. I saw the patient shortly after this, probably from two to two and one-half hours after the rupture of the membranes and the attainment of full dilatation. It was evident that there was some obstruction to delivery. Contractions of the uterus were violent and prolonged. The fetal heart was irregular, carying from 100 to 169, with considerable passage of meconium. The patient’s pulse was then I12 and temperature 101’. Vaginal examination revealed a face presentation with the chin to f.he Ieft and posterior. This was wedged tightly into the brim of the pelvis, and there was no advance with the uterine contractions. While the baby was large, the patient had an entirely adequate bony pelvis and, due to previous childbirth i.njuries, there was no obstruction from the soft parts. It was apparent that de-

IiverJr shoul~l be ac~~omplihhe~l as quickly 2,~ possible in the interests uf both mother and baby. The patient had a11~ead-y had 11’6 gr. of morphine and 1/150 of rcopolamine five hours previously with rcc+&cther-oil four hours previously. Under deep ether anesthesia in the delivery room, it was found that the uterus was moderately tight !lut would relax and the presenting part could be displaced from the brim of the pelvis. Internal podalic version seemed to be the best method of delivery. The cervix was fully dilated and fuller effaced. Because of the persistent tone of the uterus even under an anesthetic, I/> cc. of adrenalin ch!oride l-1000 was aduriui&ered intramuscularly. E’ollovving this there was prompt relaxatiou of the uterine muscuiatureJ allowiug internal podalic version to be aeirornplish with comparative ease. Vith the version completed a nine-and-thrtctquarter-pound male child was slowly extracted without diftlculty. The after-coming head was delivered easily and without the use of forceps. The baby showed marked aspliysiation and pallor. Respirations were established artificially. The placenta separated spontaneously at the enc! of five minutes and was easily expressed from t,lre vaginal vault ant! cervix without unu~mal bleeding. After a change of glove3 the birth can;ll was thoroughly explored. No lacerations could be detected in the vaginal vault, cervix, lower uterine segment, or fundus. The uterus seemed to lack tone and remained large, and there was a tendency to excess bleeding. This failed to respond to the usual oxytocics administered by hypodermic The uterus am1 vagina were tightly packed wit II iodoform gauze. 411 bleeding was cont,rolled. The fundus was now e:rsily palpable as a firm ball rising two-thirds of the way to the umbilicus. The patient’s general condition was good. The blood pressure was 1X0/90 and pulse 90. Patient was returned to bed. About two and one-lmlf hours after delivery the patient, was suddenly seized with sharp pain in the right upper quadrant of the abdomen which radiated upward into the right shoulder. The pulse was 100 and the blood pressure 120/80. The entire abdomen was reported to be tender. Pain was controlled by morphine. Three hours later she again required morphine for the upper abdominal and shoulder pain. The patient IV&R vomiting and was given 1,090 C.V. of normal saline, intravenously. 1 saw the patient at this time. Her genera! comtition was good, and her abdomen wa:, >omewhat tender. The pulse remnine{ at about 100 to 110 Tvitli no drop in blood pressure. There was no bleeding. Pos~ihlr undetected uterine rupture was considered, but since the bleeding had been controlled and her sgeneral condition was good, laparotomy was not done. During the night xlre requiretl several hypodermics of morphine to control pain and restlessness. The pulse increased in rate up to 150 and temperature rose to 101”. There was profuse sweating. A bloo(l count taken early the next morning about ten hours after delivery showed hemoglobin of (iti per cent: red cells 3,150,000, white The white count repeated four cells 17,800 and polymorphonuelears 92 per cent. hours later, that is, about fourteen hours after delivery, showed white cells 28,000 and polpn~orpl~onucleart 92 per cent. Twenty-four hours after delivery her blood pressure was 120/90. There was gcneralized abdominal tenderness and distention, pulse was 140 to IfiO, and the patient was extremely ill. She was given a clysis of 5 per cent glucose, and arrangements Four hours later after receiving the transfusion the were made for transfusion. pulse was 152, the abdomen was more distended and markedly tender, and there was persist,ent vomiting. The blood count, at this time SIR, hemoglobin 95 per cent, red cells +rjXI,OOO, white cells 23,400, and polgnlorpllonuclears 92 per cent. At this time it was our opinion that this patient wit* suffering from acute peritonitis probably due to a tear through the broad ligaments or through the uterus. Her condition was 11-e felt that our only hope would be an exploration under lo& anes, very poor. thesia.

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Upon opening the abdomen it was found to be filled with dark serous blood-stained fluid, the peritoneum was dull and glazed as was the surface of the intestines in the lower portion of the abdomen. There was no fresh blood. The uterus was firmly cSontrxcted. 1 felt tlmt there must be a uterine tear to account for the blood-stained ‘duid and slight iodoform odor as well as the peritonitis. However, no rent was at once apparent. A careful search revealed an area, far down on the right side posterior to the right broad ligament in the lower segment of the uterus, with a small hole about 0.5 C.C. in diameter into which a knuckle of iodoform gauze protruded. Only a minute opening was present through the peritoneal surface. The fluid was quickly evacuated from the abdomen with suction, and due to the extreme condition of the patient, the operation was rapidly terminated by placing three cigaret drains, the first at the site of the small hole in the uterus, second into the right flank and the third posterior to the uterus and into the culdesac. These were all brought out through the abdominal wound, since we did not wish to disturb the uterine and vaginal packing by bringing t,he drains through the vaginal vault. 1f-e believed that, if necessary, at a later date such dependent drainage could be established. The abdomen was closed with througll-and-through sutures. She was given a clysis following this operation and this was repeated several times in the next few days. The stomach was drained by means of a Wangensteen tube for two days, following which slie was able to retain food. The bowels responded to enemas, and the uterine gauze lvas removed twenty-four hours after operation. The patient had rather a stormy convalescence for the first ten days after mhich t.he functions mere normal, the temperature normal, and she was discharged from the hospital on the thirtieth day after operation Tvith the wound nearly healed. Pelvic examination at that time mas entirely negative.

COMMENTS I believe that this woman must bear a charmed life and &at we were very fortunate in the outcome of this case. Perhaps the selection of the method of delivery was unwise. Latzko extraperitoneal cesarean section might have been chosen. The rent in the lower uterine segment was so small that it was not detected when careful examination of the birth canal was made following delivery. The sudden abdominal pain radiating to the right shoulder together with the restlessness of the patient,, the high leucocyte count with high rate of polgnuclear cells, even without the signs of extensive intraperitoneal hemorrhage, should have been interpreted as due to uterine rupture, and laparotomy should have been done a few hours after delivery, rather t,han twenty-four hours later, when a well-developed peritonitis forced the issue. (Certainly the risk to the mother would have been less. 59 EAST

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Salberg and Brunet: Trichomonas Disease and Treatments, Virginia

Vaginal M. Monthly

Infestation:

A Discussion

of the

63: 223, 1936.

The authors state that they have tried and found unsatisfactory the following methods of treatment: (I) tincture of green soap, drying, and kaolin; (2) pyroligneous acid, boroglycerin; (3) stovarsol as a local application; and (4) silver pierate. At the present time they are using a powder eonsist,ing of oxyquiline, boric acid and talc after a thorough but gentle cleansing of the vagina, and feel that so far it has proved most satisfactory. EUGENE

8. AVER.