Some acquired bony abnormalities influencing the conduct of labor

SOME ACQUIRED

BONY ABNORXALITIES THE CONDUCT OF LABOR” With

ADRIAN

MT.

Reports

of Recent

M.D.,

VOEGELIX,

AKD

the

h-enkwgto-n

Cases TJ. MCCALL,

MILTOX

M.D.,

PA.

PHIL~\DELPHIA, (From

INFLUENCING

lIospitn1

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UCH has been written about labor in women with abnormal bony pelves. Most of these pelves are congenitally abnormal. In this paper, however, we are concerned only with those abnormalities which have been acquired, due to either trauma, specific disease, or to neoplasms. It must be kept in mind t,hat some of these conditions can affect the bony pelvis directly. Ot,hers, in the course of time, can exert an indirect effect through abnormality of t.he spine or lower extremities. Schauta, Litzmann, Williams1 and more recently Caldwell and Moloy’ have included acquired abnormalit,ies in their classifications of the pelves. For purposes of reference the following simplified classification is suggested. Bo~v

ACQUIRED I.

II.

AS

AS

ABN~R~L~LITIES

rNFLUENCING

THE

a result of Trauma A. Fractures B. Dislocations

CONDuCT

Pelvis

Pubis Ischium Ilium Saerum coccyx

Spine

Dorsal Lumbosacral

Lower Extreni. . it,v

Upper Femur Hip

c

a result of Specific Disease A. Bacterial Infection ~Tuberculosis 1 Osteomyelitis B. Dietary Deficiency Rickets and Osteomalacia (\. Miscellaneous Diseases of Nervous System Osteoarthritis Acromegaly P&get’s, Multiple myeloma,

(Polio) Syphilis,

OF Lasoa

Eehinococ-

CUS

Cysts,

etc.

111. As a result of Neoplastic A. Benign B. Malignant

Disease

Recently we have had experience with cases in each of these main categories which will serve as examples.

Trauma TYntil the advent of fast motor travel in recent years, the incidence of pelvic fracture as a complication of labor was comparatively rare. H. (j. HirsP in the original edition of his Textbook of Obstet~ric.~, publi&e(] *Read

at

a mreting

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the

Philadelphia

Obstetrical Ml

Society,

December

3, 1943.

in JN!)S, dates:

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0.S I~I+ ~111 of all l’rw~tttt~~:s ittvolvc

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When one consitlcrs lhal 211 gt*;rv(l in,jrtCcs 01’ t tlcl IwIG rhttd Iktally, t.he rarity of a pclvic~ deformit.y ;iqwndt~nI npon united frwtrtres of’ a pelvic hotlta it1 :I \YO~IIR~I (>I’ cltildhrwt*inc it.gfa tt~ti~’ 1~ nl’pt‘t’ciated. ” In recent years, however: ihc incidence of I)elvic fracture has greatly increased. At the Kensington Hospital for Women, three such cases have been encountered by 11sin the past 28 tnonth~. It was surprising, therefore, to find so few C~SCS report,&1 in the English language. Standard textbooks on obst,etrics briefly mention the subject, or ignore it entirely. The 1941 edit,ion of Williams’ Obstetrics” g&s in essencethf, samematerial that was included in B. Ct. Hirst ‘s original edition in 1898. There are a number of f’actors which recent,ly Harry influenced t-he illcidence of pelvic fracture ill women of childbearing age.” The widcspread use of the automohilc, and the ever increasing speed of thescl vehicles have been a prime factor. Fractures of all kinds have become more prevalent and fract,nres of t,he pelvis have become relatively mart’ common than ever before. They are quoted by Kellog Speed” as comprising 3 per cent of all fract,ures. 111 former years, Ihe vast, majorit) of fractures of the pelvis occurred in men, but in t,he most recent series of casesfrom 44 per cent to 50 per cent’ of these injuries occurred in women. The female pelvis is known to be more frail than that of the male, and so we may expect IO see an ever increasing number o-f pelvic~ fractures, not only because of ;~utnmobile~trarcl. bnt also because womet~ are filling men’s jobs in industry now more t.han ever before. h~wt.hc~ important factor is the decreased mortality in cdases of pelvic fracttur~~. Formerly up to 50 per cent of the patie& diced. Rercntl,v, Eliason and Johnson? reported but five deaths in a series of sixty cases of acute fracture of the pelvis. Severs reported but one death in his series oi’ fifty-one cases. Fractures may occur in almost any portion of the pelvis. Eighty per cent of the cases have multiple fractures. Common sites are the rami of the pubis and ischium, and the alae of the ilium. Fractures of the pelvis are usually the result of severe impact. Eighty per cent, now occur in automobile accidents. The injury commonly occurs as the result of the passenger in the rear seat of an automobile being thrown forcibly against the side of the car. Being thrown from a car, or crushing accidents are not unusual happenings. Occasionally, however, simply falling on an icy pavement, or tripping over a rug may cause pelvic fracture in women. From the obstetric standpoint, the lateral crushing fractures are the most important because greater distortion of the pelvic inlet is likely to result. Fracture of the descending ramus of the pubis is of serious import if there is a great deal of displacement because the outlet of the pelvis may be encroached upon. A severe fracture about the symphysis pubis with separation or displacement is dangerous because of the positlmOSl

VOEGELIN

AND

MC

Ca4LL

:

BONY

ABNORMALITIES

IN

LABOR

363

sibility of injury to the urethra or bladder upon descent of the presenting part, even though no such injury had been evident at the time of the fracture. These facts are extremely important from the medicolegal point of view. As these accidents increase in young women, the obste&cian will be called upon more frequently to give testimony in court. In these instances, it would be well to bear in mind the favorable effect that is exerted by the lapse of time. After a few years have passed, some of the most severe cases of pelvic fracture are surprisingly free of excessive callous formation or severe pelvic deformity. Quite often nature helps to compensate for these deformities by bringing about premature labor or producing a small baby. In giving expert testimony in these cases, we should determine if possible the type of pelvis present before the fracture occurred. A fracture can occur in a justo-minor or funnel-type pelvis just as well as it can in the gynecoid type. To remember this might save embarrassment during cross examination. The conduct of labor in cases with fracture of the pelvis depends upon the degree of distortion present, the size of the baby, and how recently the fracture occurred. Elec+ise ccsarean section should be done where there has heen a severe lateral crushing injury causing obvious obstruction. This operaCon should also be done in cases of marked displacement in the region of the symphysis pubis where injury could occur to the urethra or bladder. This also is probably the best procedure in those cases with acute fracture of the pelvis with displacement, if labor starts. In borderline cases of inlet contraction, a trial of labor can always be employed t.o see if engagement occurs. It is safe to say, howe%er, that most cases will deliver vaginally without undue difficulty. It is often wise to terminate the’ second stage of labor early with forceps in order to lessen the strain on the affect,ed region. The dislocation of joints due to trauma sometimes may cause concern. Dislocation of the bead of t,he femur usually causes .no marked In case of bilateral subpelvic deformity even though it be congenital. luxation, the heads of the femora may project into the pelvis through the sciatic notches when the patient is put in the normal abduction position for labor. This causes marked bilateral narrowing of the pelvis. Verning” has delivered sixteen such cases normally simply by abandoning the obstetric position and adducting the legs. Forward displacements of the coccyx with ankylosis of the sacrococcygeal joint due to an old injury are met with occasionally. Hirst and WachP have summarized this condition well. While this may cause dystocia at the pelvic outlet, it usually is not serious. The delivery is ordinarily completed with low forceps and the obstructing coccyx forcibly pushed backward. It is not common for the mother to have residual symptoms aft,er this procedure, although occasionally t}kc coccyx must be removed surgically.

Specific Disease Tl~c second categoq- in uur classification inel udes those abnormalities caused by a specific disease. These cases a.re uncommon; those due to bacteria, especially tuberculosis, arc seen most frequently. The rachitic pelvis wa.s at one time a rather rommon cause of pelvic dystoria.. Fortunately, at least. in most pa.rts of this country, this sequela of dietary deficiency is now seldom seen. 1Tndcr the miscellaneous group of bone diseases which includes syphilis, Paget.’ disease, multiple myeloma and such entities, the COUPSC of labor is seldom affected. Occasionally, ccchinococcus cysts of the pelvic. ring will cause dystoeia. De Sa ‘s” case of bizarre crippling clue to arthritis deformans and Bringle’s’? interesting ease of acromega.ly, both dcllivered their offspring spontanc111 cases of old 1)oliompelitis wit,11 unilateral la.meness! t,herv ously. is sometimes a slight obliclnity of the pelvis. but ISVCI as stww as in those cases in which t,he lameness is due to hip disease. ITnder. bacterial disease, osteomyelitis 01 the pelric bones has been described in detail in Wilensky ‘sJR excellent. monograph. In our esperience, this disease has not cansed severe pelvip dystocia. We, therefore, direct. our attention to tuberculosis since NY’ recently have had experience with a case of low Pott ‘s disease and two cases of t,uherculous hip joint disease. Before the tuberculin testing of’ cattle, 1hese complicat,ions were more common. Pott ‘s disease, causing kyphotic pelvis. is commonly cluotcd as occurring once in every six thousand labors. When kyphosis occurs in the dorsal region, there is usually a compensatory lordosis, so t,hat, the pelvis itself is not greatly atYecte(l. tIowerer. thfl qihbus or hump may be sit.uated in the lumbar or sacral region. (:cnerally speaking, the lower t,he gibbus, the grrater tht> pelvic dcformit..v. although the greatest deformity becomes manifest when the kyphosis is situat.ed at the lumbosacral junction in the region of the promont,ory of the sacrum. A t,ypical kgphotic pelvis’4 is charactrrized by an elongat,ed conjugata vera. and a contracted outlet. This is brought about, by t.he fact that the body weight transmitted to the lumbosacral hump is direct,ed both downward and backward. This lat,ter force draws the promontory of the sacrum backward and upward thus increasing the conjugata Vera. When t,his occurs, the post,erior ext,remit.ies of t,he innominats bones arc pushed apa1-t rotating their upper portions outward and their lower portions inward. This causes a. transverse contraction of the outlet, by bringing the ischial spines and tuberosities closer together. As t,he upper port’ion of the sacrum is rotated backward its lower portion is pushed forward thus narrowi~~g the posterior sagittal diameter of the outlet. External measurements of il. kyphot,ic pelvis reveal the distance briwrert the iliac w&s to be rqual to, or greater than, that het ween the two t rochanters. The diagonal conjugate is deep. The hiischial is small as is also the posterior sagittal measurement.

When labor starts, the engagement of the presenting part may bc interfered wit,11 because the uterus many times iuelines forward due to the fact that the abdominal cavity is shortened in a low kyphosis. This usually may be remedied by the application of a tight abdominal Knder. Ordinarily, however, no great difficulty is met with until the presenting part reaches the region of the ischial spines. If the sum of the biischial and posterior sagittal measurements equals fifteen cm. or more, no great difficulty in performing a vaginal delivery need be anticipated. If the sum of these two measurements is less than 15 cm. and a good-sized living baby is present, suprapubic delivery is the procedure of choice. Tubercnlous coxitis when it occ’urs in early life nearly always causes an obliquely contracted pelvis.14 The distortion is almost always on the healthy side. The diseased leg is shortened so that in walking the body weight is transmitted in great part to the well leg. This tends to flatten the iliopectineal line and the sacrum is rotated to some degree about its vertical a.xis, so that its anterior surface looks toward the well side. The pelvis is affected throughout from the inlet to the outlet. X-ray pelvimetry is of prime importance in evaluating the prognosis of labor in these patients. If it appears probable after such a study that engagement will not occur, cesarean section should be performed before the onset of labor. Otherwise, a trial of labor should be utilized to see if engagement takes place. The majority of cases will deliver spontaneously. Some authorities feel that in caseswhere the ankylosed leg assumesan awkward position and indications for a forceps delivery exist, internal podalic version gives better results because of difficulty in applying the forceps.

Case Reports I. Fracture$ Pelvis CASE L-MEL M. W. This 31-year-old gravida i, para 0 was involved in a serious automobile accident at eight months’ gestation. She suffered a double fracture of the horizontal ramus of the left pubic bone (Fig. 1). She was treated for a month with bed rest on a Bradford frame. At term, the head failed to engage, and because of the recent pelvic fracture, a cesarean section was done and a living seven-and-ahalf-pound infant delivered. A year later, this patient again became pregnant. At eight months’ gestation, an x-ray of t,he pelvis (Fig. 2) revealed complete healing of the old pelvic fracture without significant deformity. She was allowed to go into labor spontaneousl> at term, and was delivered after a short uneventful labor with outlet forceps of a living eight-pound child. Her puerperium was uneventful and she now is enjoying normal health. CASE 2.-Mrs. R. W. This 2%year-old gravida iv slipped and fell upon an icy pavement at eight and a half months’ gestation. She was unable to walk, SO was taken to the hospit,al where an x-ray revealed a linear fracture of the right pubic bone extending from the symphy& pubis to the obturator foramen. There was no displacement. The patient was treated with simple bed rest. After eight days, she went

ilit 12Lbor SpOIlt~~l~(~USl~r ail(l Was dC~liV(llIYt 0t ll~~~l~lal C\lII-lVLYl1 t)abl The puerperium was eight hours later wit,11 the aid ol’ outlei. forceps. normal. Two weeks following delirw~~, another x-ray showed 110 change from the previous film exc+ept, for the presence of beginning of callous formation. The patient. was thou able to walk and returned to heI home a few days later. Al. the j~~st:nf- time, she is again pregnant and has no symptoms whntsoeoer. CASE 3.-Mrs. BI. D., 23-~~~-old gravida i, para 0, who had been in a serious automobile accident fivt> years previously. At that time, she sustained multiple fractures of the pelvis with displacement of fragments of the rami of the pubes and ischii. The sacrum was also fractured and the bladder punctured. She visited one of us when she was three months pregna,nt. X-rays were t,aken (Fig. 3) which showed marked distortion of the pelvic inlet due to old lmitccl fractuws, esp+ il

Fig. 1. Fig. 2. 3’ig. l.-Patient at 8 months’ gestation with acute fracture of the horizontal ramus of the left pubic bone with some displacement. Delivered by cesarean section. Fig. 2.-Same patient twenty months later with her second pregnancy. Note how the contour of the pelvis has been almost completely restored. Delivered uaginally.

cially of the left pubic bone, The left obturator foramen showed 75 per cent diminution in its anteroposterior diameter. The body of the left pubic bone was seen to be impacted into the superior and inferior rami causing great narrowing of the forepelvis, although the internal conjugate measurement was 10 cm. and the greatest transverse diameter was 10.4 cm. The patient went’through a normal prenatal course without change in t,his picture as shown by repeated x-rays. Because of the previous bladder injury and the obvious pelvic distortion, it was decided that an elective cesarean section would be the wisest, means of delivery. She was admitted to the hospital a week before the estimated date of confinement, but went into labor early in t,he morning of the day she was to be sectioned. After an easy labor of five hours’ dura.tion, she spontaneously delivered a living six-and-a-half-pound child. ‘&e patient had an uneventful puerperium. X-rays taken ten days after deEvery showed no change whatever from the previous films.

II. Cases of Tuberculous Hip Disease CASE 4.-Mrs. I). B. A case of a 20-year-old gravida iii who had had two previous cesarean sections before her first visit to us. She gave a history of hip disease since the age of ten years, and had walked with a limp ever since. X-ray taken of the pelvis showed a characteristic tilting but 110 deformity of the pelvic ring. Information was obtained that the previous cesarean sections had been done because of increasing hip pain during the last several weeks of pregnancy. It was obvious, however, from both clinical and x-ray. measurements that the pelvis was ample in size. Because of the previous sections and the severe pain that always occurred near term, another cesarean section was done and a Pomeroy sterilization carried out.

Fig. 3.-Multiple fractures of pelvis and punctured bladder sustained Ave years befare first pregnancy. Note the contracted forepelvis and bizarre contour of the left pubic bone and obturator foramen. Delivered vaginally. This picture was taken at three months’ gestation.

CASE 5.-Mrs. N. A case of a 29-year-old gravida i, para 0, who had tuberculous coxitis when a child. She then developed an ankylosed hip with marked tilting of the pelvis. X-rays revealed only a slight oblique contraction of the pelvic inlet. She was delivered without complication of an eight-pound baby with outlet forceps. A year later, she spontaneously delivered a nine-and-a-half-pound infant. The only ,unusual procedure that had to be used in delivering this patient was the pulling of her involved leg laterally with a sheet. This had to be done in order to give room for delivery because the affected hip was ankplosed and fixed in adduction. III.

Kyphotic

Pelvis

CASE 6.-Mrs. I$. B. A case of a 2%year-old gravida i, para 0 who gave a history of having had trouble with her spine since she was six years old. She had subsequently had bilateral psoas abscesses which drained for years but finally closed up. Physical examination revealed

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.tMEKIC.\S

.JOIJRNAI,

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(;YSECOLO(;T

a gibbus in the lumbosacral region. The pelvic inlet was apparcntlj, horizontal and the tlroracic cage rested upon thtb alar of the ilii. The pelvic measurements were : Int,raxpinous I ntercrextal I nteriro~llantoil:

26 cm. 29 cm. SS cm.

Fig. 4.-Kyphotic pelvis with gibbus in Iumbosacral regidn. This film w&s taken at term. Note the engaged head with the body obliquely forward; the latter is due to The a plication of a tight abdominal the great shortening of the abdomin& cavity. binder helped to correct this. Delivered vaginally wit.R midforceps.

X-ray showed the upper portion of the sacrum to be pushed posteriorly and its lower portion to bc pushed forward. Apparently, the patient would have normall?- had a ~-ery spacious pelvis and even though the inlet was now dilated, the outlet, while it was somewhat contracted, seemed ample for the passage of a normal-sized baby. Therefore, she was allowed to go to term and have spontaneous labor. At this time she had an extrrmtdy Ixndnlons abdomen because of t’he shortness of her abdominal cavity. (Fig. 4). An abdominal binder was applied. I,abor progressed normally until the vertex reached midpelvis where it became arrested. She was delivered after seventeen hours of labor with midforceps of :III (light-pound three-ounce infant. The puerperinm was nolmnl. Neoplasms Our third category embraces abnormalities due to neoplasms. These are unusual but interest,ing. I\;eoplasms of the spine ordinarily cause no difficulty in pregnancy unless they involve the sacrococcygeal region and there are but, few cases of this sort rcporled. Those affecting thr femur may make adjustments necessary in the conduct of labor. There are very few casesreported in t,he literature’” of primary sarcoma of the upper femur associated with pregnancy. Such a rase (Fig. 5) is now under the observation of one of the ant,hors and will be report,ed later.

Tumors of the pelyie girtll(J c;~n, Iwxever, srrious dy$ociu.‘” Of the malignant tumors, 5 per cent of osteogenic sarcomas, which is a neoplasm of young people, occur in pelvic bones, according to Francisco.17 Metastatic carcinoma frequently involves the pelvis, hut usuall\ is seen in older individuals. The benign neoplasms are the most common. These are usuall,v bony esostoses which may he found over the iliopectineal eminences, the crest,s of the pubis, or over the pelvic joints. Like the enchondromas, which grow rapidly during pregnancy, the) often cause serious obstruction to labor. These usually are symptomless, and therefore oft.en are not recognized until the)- hare arrested the progress of labor. In one series of thirty cases quoted by Williams,” twenty-one cesareali swtions and three tlestructire operations upon the fetus were necessary. While such tumors arc seldom encountered, the obstetrician should have knowledge of them and keep in mind their possible presence in vague cases of dytocia CiIIlSt'

Summary 1. A simplified classification of acquired bony pelvis abnormalities and their effect. upon the conduct. of labor has been presented and discussed. 2. Cases recently category. 3. upon tures 4. tive

seen have hew

presented

as examples of each main

It. is our opinion that. mow emphasis in leaching should be placed acquired anomalies of the pelvis, cqwcially pertaining to fracof the pelvis which arc rapidly increasing in frequency. After st,udy of these acquired anomalies, it is found that operadelivery in such cases should be the exception rather t,han the rule.

References 1. Hart, D. B.: Edinburgh M. J. 19: 52, August, 1917. 2. Caldwell, W. E., and Molop, I-I. C.: Air. J. OBST. Bi GYNW. 26: 479, Octohor, 1933. 3. Hirst, B. C.: Textbook of Obstetrics. 1 cd., Philadelphia, 1895, W. B. Saunders co. 1. Stander, H. J.: Williams Obstetrics S ccl., New York, 1941, D. Appleton-Ceiltury co., Inc. 5. Schuman, W.: Bar. J. OBST. & GPNEC. 23: 103, January, 1932. 6. Speed, K.: Text.book of Fractures and Dislocations, 4 ed., Philadelphia, 1942, Lea and Febiger. 7. Eliason, E. L., and Johnson, J.: Clin. North America, December, 19Z7. 8. Sever, J. W.: New England J. Med. 199: 16, July 15, 1928. 9. Verning, P.: J. A. M. A. (Abst.) 87: 1346, Oct.ober 16, 1926. 10. Hirst, J. C., and Wachs, C.: Ali. J. OBST. & GYNEC. 7: 199, 1924. 11. DeSa, H. D.: J. Obst. & Gynaee. Brit. Emp. 44: 337, April, 1937. 12. Bringle, C. G.: Memphis M. J. 12: 72, May, 1937. 13. Wilensky, A. 0.: Arch. Surg. 37: 371, September, 1938. 14. Barbour, A. H.: Freeland; Vail, New York, 1885. 15. Wilson, J., St. George: J. Obst. & Gynacc. Brit. Emp. 43: 389, June, 1941. 16. Bick, E. M.: J. Bone & Joint Surg. 19: 40,2, April, 1937. 17. Francisco, C. B.: J. A. M. A. 99: 1845, Nov. 26, 1%“. 5601

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