The Fate of the Living Viable Babies in Extrauterine Pregnancies

THE FATE OF THE LIVING VIABLE BABIES IN EXTRAUTERINE PREGNANCIES 1\:L\x

SPTF:R,

l\LD.,

,J.\CKSO:\\'ILLE, FLA., A:\'D c~:LES'fE WICHSEH,

l\LD.,

~EW ORLEANS, LA. ( Frnm fhf' Drpnrtments of Obstetrics and Gynecology, Lou·isiana State Fnirersity School of

}[edicinc and Clwrity Hospi·tal of Lrruisiana)

HIS paper was written with the idea of dete1·mining, as nearly as possible, from the limited clinical material available at Charity Hospital of Louisiana, at New Orleans, and from a survey of the literature the fate of the viable babies delivered from extrauterine pregnancies. Only cases of twenty-eight or more weeks' gestation with babies born living were selected. l·'orty-onc additional cases of living, viable babies in abdominal pregnancies are presented graphically from the literature to supplE'ment those recorded by Sittner," Hellman and Simon, 2 and Mitra. 4 Pour new cases are presented from Charity Hospital, at New Orleans, in addition to those recently reported by Bea(•ham and Beacham. 1

T

\VinckeF in discussing the deformities of extrauterine preg·nanries stated that 75 per cent of all the deformed children included deformities of the head. half of them deformities of the lower extremity, and 40 per cent deformities of the upper extremity. The more sheltered thorax, abdomen, and genitourinary system were deformed in only 3 or 4 per cent of the babies. Of 316 living, viable babies reviewed by Hellman and Simon 2 in 1935 from the world literature, including those previously reported by Sittner, a specific statement as to the development of the babies was made in only sixty-four cases. 0£ these, thirty, or 46.6 per cent, were found to be defonned. One hundred fifty, or 44.3 per cent, of the babies survived for eight days or more, and of these a specific statement as to the development was made in forty-one babies; fifteen, or 36.6 per (•ent, were found to be deformed. Stabler," in 1938, reviewed 266 cases from the world literature. Of 266 living, viable babies delivered from abdominal pregnancies, 152, or 57.1 per cent, lived for eight clays or more. The fate of only one was undetermined. Twenty-eight, or 10.5 per cent, of these babies were recorded as being deformed. Lelling, 3 in reviewing 106 cases in 1938, found that development was mentioned in only 82 of the 106 babies. Of these, thirty-two, or 39 per cent, were rerorded as deformed. JVIitra/ in reviewing the world literature on advanced extrauterine pregnancies in 1942, found that of 179 extra-uterine pregnancies of more than five months' gestation only 23.5 per <'ent delivered living, viable babies. Of these, a specific statement as to the development was made in thirteen, ten of which were rreorded as being deformed. Beacham and Beacham,' in a report of twenty abdominal pregnancic's from Charity Hospital, at New Orleans, found that onl~· thrre, or 15 per rent, delivered living, viable babies. In our review of forty-one additional cases in the literature we found that a speeific statement as to tlw development was mad<' in thirty-one babies. Twelve, or 38.7 per cent, of thPse babies were found to he deformPll. Ten. or 24.3 per cent, of the babies died before the eighth day. Pour new cases of extrantNine pregnanciE~s \Vith living, viable babies arc reported from Charity Hospital. 489

490

~U'l'ER

AND \\'lCHSER

-\m. J. Ob't. & Gynec. March, 1948

Case Reports CAsE 1.-K P. The patient, a Negro female, gravida i, para 0, whose las1 menstrual period was Nov. 23, 1944, was admitted to Charity Hospital on .July 25, 1945, with the chief eomplaint of pain in tlw lower abdomen, and vomiting. When she was three to four months preg·nant. the pat.ient had an attaek of severe lower abdominal pain assoeiated with fainting· l'r·om whieh she recovered spontaneously. The patient's blood pressure was 135/100. Her abdomen was the size of The an eight months' pregnancy, and fetal parts were quite superficial. abdomen was markedlv tender. Fetal heart 1olH's were 140 in the left lower quadrant. Sterile vaginal examination was done. The (•ervix was pushed forward, soft, long, and patulous. Membranes or fetal parts were not felt through the cervical os. A shoulder was felt posterior to the cervix. Urinalysis wa~ negative. Hemoglobin was 10 grams. X-ra~- revcaleil rf'phalir presf'ntation with back to right. No uterine shadow was seen. Preoperative diagnosis: abdominal prt•gnarH·y. Laparotomy was performed on July 2G, 1945. t:terus was found to be thl· size of a ten weeks' pregnancy, with a 5 em. fibroid extending to the left. A male infant was free in the abdominal cavih without a sae. A small amount of fluid was found in the abdominal cavity.· Male baby weighed 4% pounds. and had a deformed head and clubfeet. He was in poor rondition after birth and died the same day. The cord was tied off elose to the plarenta and the ahrlomen was closed without drainage, leaving the plaecnta in situ. Postoperative course was afehrih' after the fir,;t day, and the patient ·wa~ discharged on the seventeenth 1la,,·, at whirh time the placental mass had not regressed in size. Patient was readmitted on Feb. 7. 1946, with tlw rhief eomplaint of pain in the abdomen. She was afebrile during tht• sta.'· in the hospital and was operated on Feb. 19, 1946, for removal of retained placenta. The placenta was found to be attached to the rul-de-sae, posterior surfar·e of the right broad ligament, lateral wall of the pelvis, posterior pr>lYi(• wall, reetosigmoid, and mesoappendix. In order to remove tlw placenta it was necessary to do n subtotal hysterectomy, bilateral salpingo-oiiphoreC'tom~-. and appendeC'tomy. Th<· patient was discharged on Feb. 28, 1946, in good eondition. CASE 2.--V. R. The patient, a 28-year-old 1\egro female, whose last menstrual period was April 1, 1946, was admitted to Charit~· Hospital on ,Jan. 8. 1947, with a history of recurrent abdominal pains ever.v two to three minutes. nausea, and vomiting. On September 17 the patient had an episode of bleeding. Since September, 1946, she had been having periodic attacks of pain in the lower abdomen more severe on the right side, which were relieved by vomiting and aggravated by any activity. The patient said that she felt the baby move onb· on the right side. Blood pressure was 110/80. Heart and lungs were negative. Abdomen was enlarged to the size of a term pregnancy, vertex pref.:entation, head floating. Fetal heart tones were best heard in the right lower quadrant, and their rat(' was 152. The patient was recorded as having hard pains ever;v three minutes. Urinalysis was essentially negative. Hemoglobin was 9.5 grams. Diagnosis of breech presentation was made whirh was confirmed by x-ra~·­ X-ray also showed a peculiar shaped occiput in left flank. On Jan. 9, 1947, the cervix was found to he soft, long, and would barely admit one finger. Exploration of uterine cavity revealed no membranes nor fetal parts. It was found to be about 10 rm. long-.

Volume 55 Number .l

BABY IN EXTRAJJTElUXE PREGNANCY

-1-91

Patient had a laparotomy on Jan. 9, 1947, with preoperative diagnosis of abdominal pregnancy. When the abdomen was opened, the fetal sac was found in the abdominal cavity. This was opened and a living, male infant weighing 6 pounds was delivered by breech extraction. The baby had a plastic deformity of the head and a right clubfoot, and contraction deformities of both arms. The placenta was attached to the bowel, the omentum, and the left cornual portion of the uterus. The placenta was removed with minimum amount of bleeding. The abdomen was closed without drainage. Postoperative course was essentially afebrile. Five-month cheek-up n•vealed that both mother and baby were getting along well. CASE 3.-E. MeC. The patient, a 23-year-old Negro female,· gravida i, para 0, whose whose last menstrual period was June 7, 1946, was admitted to Charity Hospital on :\:farch 23, 1947, with the c·hief complaint of pain in thr abdomen for the past two days. The heart and the lungs were negative. The abdomen was that of a breech at term. Fetal heart tones were 140 and best heard in left upper quadrant. There was marked costovertebral tenderness. During her stay in the hospital. the patient developed enlargement of the abdomen with marked dyspnea. Vaginal examination disclosed the cervix undilated and uneffaeed. ~o membranes nor fetal parts were felt through the pelvis. 'I'emperature was 101 o F., pulse 130; blood pressure 130/72. Urine wa~ essentially negative. Hemoglobin was 11.8 grams. X-ray revealed one fetus outside of pelvis, breech presentation. No uterine wall could he made out. Preoperative diagnosis: Abdominal pregnancy at term. Patient had a laparotomy performed on l\Iarch 25, 1947, at whieh time the placenta was found attached to the left cornual portion of the uterus. Rome uterine muscle fibers extended up alongside of the fetal sac, bnt did not entirely cover it. When the sac ·was opened, it was found to be made up of three definite layers; the outside one was rather fibrous in character. The sac was opened and an 8 pound 15 ounce apparently normal li·dng male (•hild was delivered, who died in a few minutes. In order to remove the placenta. a left salpingoophorectomy and supracervical hysterectomy were necessary. The mother was discharged in good condition on the tenth postoperative day. CASE 4.-D. T. The patient, a 29-year-old Negro female. gravida v, para iii. had not menstruated since her last pregnancy in 1946. She was admitted to Charity Hospital on May 9, 1947, with a history of having had convulsions that morning and having had some sedation given her by her private physician. On admission she was semistuporous and complained of pain in the lower abdomen. She l1ad a productive cough and expectorated hlood-ting-ed sputum. She had been dyspneic for some time. 'I'emperature was 99.4° F.; pulse 160; blood pressure 164/128. There was marked edema of legs and moderate edema of anterior abdominal wall. The lungs had a few rales at both bases. The heart was enlarged 3 em. to the left midclavicular line. The abdomen was the size and C'ontour of a term pregnancy. No definite fetal heart tones were heard. At vaginal examination the eervix could not he felt because it was high and anterior. There was a :firm mass about 10 em. in diameter :filling the «nlde-sac. . The urine showed three plus albumin; hemoglobin 11.5 Om.; venous pressure 115 millimeters of water. X-ray revealed a fetus lying between transverse and in a breech. An electrocardiogram v;as strongly sugg-estive of myocardial disease. Kline test was positive.

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- ReeovCi:C,T___ -- 3·8-\vccks; -vitiT)ie; lived; female -;N"'"ic-c-o'-;d-e_n_Ju--s-.""'R~.-;-1<,--;.-.-a-n""'dc-:cCc-a-r-ric-g--g-,"""'L;:-.""'G::-.-:-A:--M-. 4 lbs. 9 oz. .T. OllHT. & GvN~;c. 39: 153, HJ40 • Maver and New---b"'r--:1-ea_n_s_, Hecovered - +:J weeks; Jived; ll.oi:n1aCflb~. Beacham, W. D., andBea.cham,-D.w.~ I Marino La. 13 oz. Obst. & Oynee. Survey 1: 777, 1!146. Hprague mul- Atl1ens, Ohio Recovered .~!3 weeks; live<] +8 hr.; female Bpragu.e, J. R., and Chappel, M._ R.-: Ohio Chappel 7 lbs. 2 oz. State M. J. 36: 520, 19!0. (Child had as~·mmetrical head and equinuR varuR.) Renner --Recovered J. Kansas M. --Sot. 42: 40 weeks; norn1al, 6 lbs. % oz.l Henr:er, l\L J.: Goodland, 24;J, 1!Hl. Kan.

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STATUS OF' FETUS SPECIAL NOTES i BIBLIOGRAPHY 40 weeks; male, normal, iOTbs. Nicholls, }t B.: AM. J. 0BST. & GYNEC. 42: 341, 19•11. I 3__oz~·~~~ -~ R-ecovered Foochow, ---l-4o weeks; lived 2 hr.; asymmet· L,in, A. Y.: Chine~e M . .T. 62: 383, .1945~ Fukien I ! rica! face, right elbow; knee , \ eould not be straightened h:ecovered -- 40 weekll; lived; normal fernal<>,l"ffato\er;-1\L ·L:~-BriC " lbs. 10 oz. 1 U"vvvered :l~ weeks; living lea£ham, atl(i' Heacham, D. 'j Obst. & Gyuec. Survey 1: 777, HH6. ( L 41-42400, Ca_s_e_X_II~·:....)------;:--1 - .-~Rccoverc~l-- :cg weeks; lidng; full terinf____
RESUI,1' TO

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Volume 5 ~

~umber

3

BABY IN EXTRAUTERINE PREGNANCY

495

A laparotomy was performed on May 13, 1947, with preoperative diagnosis of abdominal pregnancy versus uterine fibromyomas with intrauterine pregnancy. The fetal membranes were found free in the abdominal cavity. The membranes were opened and a grossly deformed living baby was found which died in thirty minutes. The placenta was attached to the uterus posteriorly between the broad ligaments, to the right iliac fossa, posterior abdominal structures, and small bowel. The cord was cut short. The placenta was left intact and the abdomen was closed without drainage. On her sixteenth postoperative day the patient is in good condition but is still febrile.

Conclusions Only about one-fourth of all the extrauterine pregnanc·ies diagnosed after the fifth month of gestation will result in viable, living babies. About onethird of all these living, viable babies delivered from extrauterine pregnancies will have major or minor deformities including those which were incompatible with life. Approximately half of all the viable, living babies delivered from ('xtraut.erine pregnancies will survive eight days or more.

Summary All the available literature on extrauterine pregnancies resulting in viable, living babies is reviewed to determine their ultimate fate. Forty-one cases are tabulated hom the literature to supplement those preYiously summarized. Four new cases of extrauterine pregnancies with living, viable babies are reported from Charity Hospital of Louisiana, at New Orleans. The authors wish to acknowledge thei;' appreciation to Drs. Adolph .Taeobo, D. W. Gold· man, and E. L. King for use of cases on tl1eir SE.'rviees.

References 1. BE.'acham, W. D., and Beacham, D. W.: Obst. & Gynec·. Survey 1: 777, 1946. :l. Hellman, A. M., and Simon, H. S.: Am. ·J. Surg. 29: 403, 1935. 3. Lelling, E.: Zentralbl. f. Gynak. 62: 2209, 1938. 4. Mitra, S.: Calcutta M. J. 39: 1 and 43, 1942. 5. Stabler, F.: Brit. M. J. 1: 779, H)38.

6. Sittner: Quoted from Hellman and Simrm,2 7. \Vinckel. V.: Quoted from Lelling.B