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Two additional cases of acute puerperal inversion of the uterus treated by abdominal replacement
TWO ADDITIONAL CASES OF ACUTE PUERPERAL INVERSION OF THE UTERUS TREATED BY ABDOMINAL REPLACEMENT BY FRHDEFCICK C. IRVING, M.D., AND FOSTEX BOSTON, MASS.
S. KELLOGG, M.D.,
H
ITHERTO we have traced the origin of abdominal reposition in acute inversion of the puerperal uterus,l described the technic and reported five cases so treated without mortality,2 and classified the condition for treatment.3 We do not feel that a further article is ‘warranted at this time. However in view of the rarity of the condition, the high mortality by other methods, the interest in it as shown by Findlay’s recent paper and because one death was reported in 1929 in Massachusetts from this cause, we feel justified in reporting two additional cases in our series. One of us (Kellogg) has somewhat modified the technic previously described. The inverted uterus is grasped at one cornu in the region of the ovary and tube and this portion of the uterus replaced with Allis forceps as in the original procedure. It was found accidentally that either with or just following ‘the reposition of this portion of the uterus the other horn flops up itself. The advantage is fewer bites in the peritoneum and on the whole less traction force is necessary. The following cases are reported unedited from the records of the Boston Lying-In Hospital. CASE 1 (Six in our series) (Irving) .-Primipara entered hospital 7 :20 P.M., April 14, 1928, in active labor with steady regular pains. She was given morphine and scopolamine. Head on perineum with fully dilated cervix at 2:20 A.M. Under gas-oxygen ether anesthesia, low forceps done after median episiotomy. Meconium stained amniotic fluid. Episiotomy wound repaired. Placenta and membranes delivered intact twenty-two minutes later following moderate Crede. No more pressure was used than with other patients. Following delivery a steady trickle of blood came from the vagina. Blood was clotted and did not appear fresh as from cervix, 1000 C.O. rectal saline. Blood pressure falling rapidly and pulse rising as fast. A suggestion of a square topped uterus low down with a crater in middle suggested inversion. Vaginal examination showed complete inversion with the rough interior of the uterus as big as an orange in the vagina. Hemorrhage continued during examination, patient rapidly grew worse. Eight hundred C.C. intravenous saline was given following which blood pressure became perceptible and pulse a little stronger. Vagina after examination was washed out with 3000 cc. saline and 100 C.C. 70 per cent alcohol. Immediate laparotomy and transfusion started.. Under gasoxygen anesthesia, abdomen was opened, uterus found inverted, replaced by the usual technic, abdomen closed in layers without drainage. 440
IRVING
AND
KELLOGG:
ACUTE
PUERPERAL
INVERSION
OF
441
UTERUS
Patient transfused again, 500 cc. eitrated blood. At end of hour blood pressure 100, pulse 124. Convalescence nonfebrile, except slight temperature rise first two days, pulse never over 100. Ready for discharge on fourteenth day. Kept on account of cardiac disease. Nursed the baby who gained. CASE 2 (Seven in our series) (Kellogg).-Primipara normal in every respect, in labor nine hours. Head on perineum and starting to crown. Gas-oxygen and ether given. Head delivered with pressure on fundus. Cord around baby’s neck, clamped and cut. Seen to be very short. Baby breathed immediately. Placenta expressed following separation nine minutes after delivery of infant. On removal of placenta, uterus seen to be projecting through vagina, relaxed and inverted completely. Moderate bleeding. Attempt was made to reduce inversion by gentle pressure on the inverted fundus. Cervix contracted and prevented reduction. Bleeding was moderate. Vagina was packed with two three-yard strips. Patient in moderate shock with continued hemorrhage. Prepared for immediate operation. Within one hour of the inversion gas-oaygeu and ether, 5 inch median low incision. Uterus found partially inverted with tubes and ovaries drawn into the inversion, ovaries being at edge. Inversion readily replaced with Allis forceps in the usual manner. Uterus which was blanched at the beginning of the operation had its normal color immediately following replacement. Abdomen closed in layers without drainage. During the hour between inversion and operation patient was in a fair amount (The of shock with a rapid fairly thready pulse, around 130 and slight bleeding. anesthesia chart, however, shows that the anesthetist could not count pulse, though it was perceptible and that the blood pressure ranged from 72 over 50 to 52 over 40.) At end of operation the patient’s pulse was better and her facies looked much better. However, she was given one 500 cc. citrate transfusion. Convalescence normal except for Operation begun at 7 :14 was finished at 7 :37. two-day temperature rise. Mother and baby discharged well.
We have now seven consecutive cases of acute inversion of the puerperal uterus treated by abdominal reposition without mortality. It may be of interest to note that five of the seven patients were primipara. We have nothing to add to our previously published comments except that with each experience we are more impressed with the simplicity and efficacy of this procedure, REFERENCES
(1) Huntington, J. L.: Boston M. &r S. J. 184: 376, 1921. Irving, and Eellogg: AX J. OBST. 6; GYNEC. 15: 34, 19%. (3) AM. J. OBST. & GYNEC: 18: 815, 1929. 475 COMMONWEALTH AVENUE. 19 BAY STATE ROAD.
(2) Huntington, Kellogg,
F.
8.:
S. KELLOGG, M.D.,
H
ITHERTO we have traced the origin of abdominal reposition in acute inversion of the puerperal uterus,l described the technic and reported five cases so treated without mortality,2 and classified the condition for treatment.3 We do not feel that a further article is ‘warranted at this time. However in view of the rarity of the condition, the high mortality by other methods, the interest in it as shown by Findlay’s recent paper and because one death was reported in 1929 in Massachusetts from this cause, we feel justified in reporting two additional cases in our series. One of us (Kellogg) has somewhat modified the technic previously described. The inverted uterus is grasped at one cornu in the region of the ovary and tube and this portion of the uterus replaced with Allis forceps as in the original procedure. It was found accidentally that either with or just following ‘the reposition of this portion of the uterus the other horn flops up itself. The advantage is fewer bites in the peritoneum and on the whole less traction force is necessary. The following cases are reported unedited from the records of the Boston Lying-In Hospital. CASE 1 (Six in our series) (Irving) .-Primipara entered hospital 7 :20 P.M., April 14, 1928, in active labor with steady regular pains. She was given morphine and scopolamine. Head on perineum with fully dilated cervix at 2:20 A.M. Under gas-oxygen ether anesthesia, low forceps done after median episiotomy. Meconium stained amniotic fluid. Episiotomy wound repaired. Placenta and membranes delivered intact twenty-two minutes later following moderate Crede. No more pressure was used than with other patients. Following delivery a steady trickle of blood came from the vagina. Blood was clotted and did not appear fresh as from cervix, 1000 C.O. rectal saline. Blood pressure falling rapidly and pulse rising as fast. A suggestion of a square topped uterus low down with a crater in middle suggested inversion. Vaginal examination showed complete inversion with the rough interior of the uterus as big as an orange in the vagina. Hemorrhage continued during examination, patient rapidly grew worse. Eight hundred C.C. intravenous saline was given following which blood pressure became perceptible and pulse a little stronger. Vagina after examination was washed out with 3000 cc. saline and 100 C.C. 70 per cent alcohol. Immediate laparotomy and transfusion started.. Under gasoxygen anesthesia, abdomen was opened, uterus found inverted, replaced by the usual technic, abdomen closed in layers without drainage. 440
IRVING
AND
KELLOGG:
ACUTE
PUERPERAL
INVERSION
OF
441
UTERUS
Patient transfused again, 500 cc. eitrated blood. At end of hour blood pressure 100, pulse 124. Convalescence nonfebrile, except slight temperature rise first two days, pulse never over 100. Ready for discharge on fourteenth day. Kept on account of cardiac disease. Nursed the baby who gained. CASE 2 (Seven in our series) (Kellogg).-Primipara normal in every respect, in labor nine hours. Head on perineum and starting to crown. Gas-oxygen and ether given. Head delivered with pressure on fundus. Cord around baby’s neck, clamped and cut. Seen to be very short. Baby breathed immediately. Placenta expressed following separation nine minutes after delivery of infant. On removal of placenta, uterus seen to be projecting through vagina, relaxed and inverted completely. Moderate bleeding. Attempt was made to reduce inversion by gentle pressure on the inverted fundus. Cervix contracted and prevented reduction. Bleeding was moderate. Vagina was packed with two three-yard strips. Patient in moderate shock with continued hemorrhage. Prepared for immediate operation. Within one hour of the inversion gas-oaygeu and ether, 5 inch median low incision. Uterus found partially inverted with tubes and ovaries drawn into the inversion, ovaries being at edge. Inversion readily replaced with Allis forceps in the usual manner. Uterus which was blanched at the beginning of the operation had its normal color immediately following replacement. Abdomen closed in layers without drainage. During the hour between inversion and operation patient was in a fair amount (The of shock with a rapid fairly thready pulse, around 130 and slight bleeding. anesthesia chart, however, shows that the anesthetist could not count pulse, though it was perceptible and that the blood pressure ranged from 72 over 50 to 52 over 40.) At end of operation the patient’s pulse was better and her facies looked much better. However, she was given one 500 cc. citrate transfusion. Convalescence normal except for Operation begun at 7 :14 was finished at 7 :37. two-day temperature rise. Mother and baby discharged well.
We have now seven consecutive cases of acute inversion of the puerperal uterus treated by abdominal reposition without mortality. It may be of interest to note that five of the seven patients were primipara. We have nothing to add to our previously published comments except that with each experience we are more impressed with the simplicity and efficacy of this procedure, REFERENCES
(1) Huntington, J. L.: Boston M. &r S. J. 184: 376, 1921. Irving, and Eellogg: AX J. OBST. 6; GYNEC. 15: 34, 19%. (3) AM. J. OBST. & GYNEC: 18: 815, 1929. 475 COMMONWEALTH AVENUE. 19 BAY STATE ROAD.
(2) Huntington, Kellogg,
F.
8.: