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Two cases of pregnancy following Watkins' interposition operation
NEW seems to be more frequently is pain on defecation.
YORK
OBSTETRICAL
affected
than
the
943
SOCIETY right
and
a characteristic
symptom
read a paper entitled Results of Operations for Prolapse of the Uterus and Bladder. (For original article see page 864.)
DR. G. M. LAWS
This was briefly discussed by Drs. J. H. Girvin
NEW YORK OBSTETRICAL MEETING
OF
FEBRUARY
and S. E. Tracy.
SOCIETY 9,19SB
Two Cases of Pregnancy Following Watkins’ Interposition Operation.
DR. CARL H. ILL, of Newark, N. J., presented (by invitation)
Mrs. D., aged thirty-seven, was operated upon May 25, 1930, for a relaxed perineum, marked cystocele, and lacerated cervix. The cervix was amputated, and a typical Watkins ’ interposition operation done. Both tubes were doubly ligated, with linen thread, severed with cautery between the two ligations and stumps buried in the folds of the broad ligament. She also had a perineorrhaphy. She menstruated last on June 4, 1930, and was referred to me for delivery on January 4, 1931. She had had three children; the first a long difficult labor, terminated by forceps. She was never well after this, having painful menstruation headaches, backaches, and a feeling of everything dropping out of her vagina. These symptoms practically cleared up while she carried the other children, She felt well during this entire pregnancy, her only complaint being frequency of urination and burning at times. Examination when she came to me showed head high, but engaged in the pelvis, a long anterior vaginal wall, the scar of the interposition operation was very definitely felt. Blood pressure normal, urine negative except quite a few white cells. On February 18 she came into the Hospital with slight pains. Abdominal examination showed back to the left, feet distinctly felt to the right; fetal heart rate 120, left lower quadrant. Pelvic examination showed head in midpelvis, pointing toward the rectum, anterior lip of cervix 10 cm. long. Diagnosis of left occiput posHer pains soon stopped; castor oil and quinine were given the night of terior. the twentieth followed by six 3 minim doses of pituitrin. At 10 A. M. on the twentyfirst, vaginal examination showed head still in midpelvis, anterior lip of cervix 5 em. long; cervix 5 fingers dilated. A sound was passed into the bladder, after catheterization, and was easily inserted for 6 inches. In fear of injury it was not passed any further, no obstruction being encountered. Caput was visible on February 22 at 4 A. a~.; living child was easily delivered with low forceps in R.O.A. position. After waiting one hour placenta was delivered manually. It was not thought advisable to use much force by Cred6’s method. She reported on April 7 for follow-up. Perineum was somewhat relaxed, vagina subinvoluted, and a slight erosion of the end of the cervix. Uterus small, antiverted, no cystocele. She is now entirely well and has no pain at menstruation. The second case, Mrs. S., aged twenty-nine, was referred to me September 4, 1931. She had had two children; the first after one hour’s labor and the second after two pains. Both babies were said to have weighed over 10 pounds: In March, 1927, she was operated upon for a marked cystocele, rectocele, and lacerated cervix. The cervix was amputated, typical Watkins’ interposition operation done, both tubes being doubly ligated with linen thread, severed with cautery between the ligation, and ends buried in the folds of the broad ligaments.
She menstruated last on February 15, 1931. Abdominal examination showed a hard, firm uterus, which was very definitely held dowu over the bladder region. Vaginal examination showed a very much elougated and thickened wall of the vagina, and the cervix was so far posterior t.hat it could hardly be frllt. She was very uncomfortable, had great difficulty in urination and had to be in bed most of Her blood pressure was normal. urine showed considerable albumin, and the time. symptoms increased, she had 4t pus. Her condition grew st,eadily worse, urinary On October I!), 1931., a typical classical cesevere pains all through her abdomen. sarean section was one, a living male child being delivered. On opening t,he abdomen the bladder was pulled way down under the pubes, and when the uterus was opened The posterior wall was extremely thin. The enthe anterior wall was 7 cm. thick. tire uterus had developed posteriorly, just as it so oft,en does in a pregnancy following a ventral fixation. So opening into the uterus could be detected where the tubes had been cut. However, the location at both horns of the uterus were sewed over by redundant peritoneum. She made an uneventful recovery and on her follow-up examination on January 4, 1932, showed perineum and cervix normal, uterus anteverted, small, no cystocele. Abdominal sear healed; patient has no discomfort. In the first ease the uterus developed normally and pulled the bladder up with it. Consequently, there was no obstruction and the baby was born normally. In the second ease the uterus entirely developed posteriorly, causing a thick anterior portion, which almost entirely obstructed the birth canal, acting exactly like a fibroms which had developed in the lower anterior segment. DR. 0. PAUL HTJkII%TONE.-I nant after the Watkins’ interposition cases is whether or not the cervix interposition operation, the OS will
have observed two patients who became pregThe most important point in these operation. is amputated. If the cervix is amputated in the not diIate in k&or.
DR. HARBECK a low-flap cesaree.n
have seen only it was not possible
HALSTEAD.-I section because
one of these cases and to do anything else.
we did
DR. ROBERT T. FRANIG-The thing that strikes me most is the question of the technic in sterilizing these patients at the time. In my own experience, which covers quite a large series of cases, probably over 500, I have noted only one pregnancy after ligation of the tubes. I lay great stress upon not peritonealizing these two transected ends in tying them with a single ligature, tying over the loop, first to one side and then to the other. I transect them with the scissors and take great care to see that the openings are parallel to each other and not peritonealized, because should reestablishment of the lumen occur the likelihood of the ovum finding the second entrance is much reduced. On the contrary, if a normal tube, just like a normal vas deferens, is buried after transection in a connective tissue sheath, the likelihood of reestablishment of continuity is greatly increased. DR. ELIOT BISHOP.-The only thing I want to emphasize, as I have many times before, is that the actual sterilization is done by peritonealization, and not by artificial blocking. We have had no pregnancies follow this theory and pr&,iee of sterilization. About three years ago we collected over 100 cases and have had a number of additional cases sinoe then. We cut off a loop of each tube over catgut ligature and leave the two ends parallel, as Dr. Frank mentioned. The ends slowly pull apart after peritoneslization, which occurs in twenty-four to forty-eight hours, We have had the opportunity of opening two or three abdomens and have been able to demonstrate this. who
DR. ALFRED C. BECK-I had had an interposit.ion
recall operation
some years ago and amputation
treating a pregnant woman of the cervix by Dr. Polak.
NEW
YORK
OBSTETRICAL
945
SOCIETY
I do not recall whether he sterilized her or not; probably he did tie off the tubes. In that case I pulled a foot through the cervix, although it was very difficult to reach. Finally, the cervix dilated and a living child was delivered spontaneously by the breech. DR. RALPH M. BEACH.-1 would like to report a case of interposition during the childbearing period by Dr. Polak at the Jewish Hospital. At about the third or fourth month this woman developed a very marked elevation of the bladder, elongation of the urethra, marked clouding of the urine, distortion of the ureters, bilateral hydronephrosis, which was followed by retention, very marked toxemia, and jaundice. When she was brought to the hospital she was very sick. We emptied the uterus at this time, very easily, by an anterior hysterotomy. There being no bladder in front of the uterus, it was a very simple procedure. Following that the patient made a very rapid recovery. DR. RALPH A. HURD.-Sterilization of women in the childbearing period when an interposition operation is done, should always be preceded by curetting. In my case the patient menstruated about the middle of May and I operated upon her in the Woman’s Hospital the first week in June. I took great care to insure her against future pregnancies, but rather inadvertently neglected to euret the uterus. It seemed that she was pregnant at that time; she became pregnant between her last menstruation and her admission to the hospital, and she went on almost to term. I suspected a low implantation of the placenta, although I was never able to prove it on account of the great difticulty of examination. I did a cesarean section and she had a live baby five weeks from term. I think the aterilization has been well done because she has not become pregnant again. The tubes were apparently occluded completely and the two cut ends were sep arated and closed, or peritonealized thoroughly. I had to make the incision way up on the fundus, practically on the posterior wall of the uterus. The bladder was drawn up to the top. DR. BENJAMIN have been avoided
had
P. WATSON.--1 interposition
not
believe been
that done.
all of these complications could I regard it as a bad operation.
DR. CARL H. ILL.-1 did not operate originally on either one of these cases. They were referred to me for care during pregnancy. Both patients were Catholics, they would not consent to interruption of pregnancy, there was nothing else to do and, so, I had to let them go through with it. It so happened that both these cases were done by Edward Ill, and in going over his records with him I found that he has done almost 600 interposition operations. He has a very careful follow-up sysHe tem and these are the only cases that he had that have ever become pregnant. has used this method of sterilization, he tells me, for the last twenty years.
DR. JOHN J.
MADDEN
Calcium and Viosterol DR.
VICTOR
JOHN
(by invitation)
(by invitation) read in Pregnancy.
HARDING
presented
emias of Later Pregnancy.
a paper
entitled
!l’he
R3le of
DR. H. B. VAN M~YCK, of Toronto, Ont., a paper entitled Researches on the Tox(For original article see page 820.)
AND
DISCUSSION DR. H. B. VAN WYCK.-One of the striking things about the toxemia5 of pregnancy has always seemed to me to be the extreme number of varying types with a certain common association, and I feel that that has been too little taken account of in all etiologie discussions. We see that factor, too, in the diftieulty that has been
YORK
OBSTETRICAL
affected
than
the
943
SOCIETY right
and
a characteristic
symptom
read a paper entitled Results of Operations for Prolapse of the Uterus and Bladder. (For original article see page 864.)
DR. G. M. LAWS
This was briefly discussed by Drs. J. H. Girvin
NEW YORK OBSTETRICAL MEETING
OF
FEBRUARY
and S. E. Tracy.
SOCIETY 9,19SB
Two Cases of Pregnancy Following Watkins’ Interposition Operation.
DR. CARL H. ILL, of Newark, N. J., presented (by invitation)
Mrs. D., aged thirty-seven, was operated upon May 25, 1930, for a relaxed perineum, marked cystocele, and lacerated cervix. The cervix was amputated, and a typical Watkins ’ interposition operation done. Both tubes were doubly ligated, with linen thread, severed with cautery between the two ligations and stumps buried in the folds of the broad ligament. She also had a perineorrhaphy. She menstruated last on June 4, 1930, and was referred to me for delivery on January 4, 1931. She had had three children; the first a long difficult labor, terminated by forceps. She was never well after this, having painful menstruation headaches, backaches, and a feeling of everything dropping out of her vagina. These symptoms practically cleared up while she carried the other children, She felt well during this entire pregnancy, her only complaint being frequency of urination and burning at times. Examination when she came to me showed head high, but engaged in the pelvis, a long anterior vaginal wall, the scar of the interposition operation was very definitely felt. Blood pressure normal, urine negative except quite a few white cells. On February 18 she came into the Hospital with slight pains. Abdominal examination showed back to the left, feet distinctly felt to the right; fetal heart rate 120, left lower quadrant. Pelvic examination showed head in midpelvis, pointing toward the rectum, anterior lip of cervix 10 cm. long. Diagnosis of left occiput posHer pains soon stopped; castor oil and quinine were given the night of terior. the twentieth followed by six 3 minim doses of pituitrin. At 10 A. M. on the twentyfirst, vaginal examination showed head still in midpelvis, anterior lip of cervix 5 em. long; cervix 5 fingers dilated. A sound was passed into the bladder, after catheterization, and was easily inserted for 6 inches. In fear of injury it was not passed any further, no obstruction being encountered. Caput was visible on February 22 at 4 A. a~.; living child was easily delivered with low forceps in R.O.A. position. After waiting one hour placenta was delivered manually. It was not thought advisable to use much force by Cred6’s method. She reported on April 7 for follow-up. Perineum was somewhat relaxed, vagina subinvoluted, and a slight erosion of the end of the cervix. Uterus small, antiverted, no cystocele. She is now entirely well and has no pain at menstruation. The second case, Mrs. S., aged twenty-nine, was referred to me September 4, 1931. She had had two children; the first after one hour’s labor and the second after two pains. Both babies were said to have weighed over 10 pounds: In March, 1927, she was operated upon for a marked cystocele, rectocele, and lacerated cervix. The cervix was amputated, typical Watkins’ interposition operation done, both tubes being doubly ligated with linen thread, severed with cautery between the ligation, and ends buried in the folds of the broad ligaments.
She menstruated last on February 15, 1931. Abdominal examination showed a hard, firm uterus, which was very definitely held dowu over the bladder region. Vaginal examination showed a very much elougated and thickened wall of the vagina, and the cervix was so far posterior t.hat it could hardly be frllt. She was very uncomfortable, had great difficulty in urination and had to be in bed most of Her blood pressure was normal. urine showed considerable albumin, and the time. symptoms increased, she had 4t pus. Her condition grew st,eadily worse, urinary On October I!), 1931., a typical classical cesevere pains all through her abdomen. sarean section was one, a living male child being delivered. On opening t,he abdomen the bladder was pulled way down under the pubes, and when the uterus was opened The posterior wall was extremely thin. The enthe anterior wall was 7 cm. thick. tire uterus had developed posteriorly, just as it so oft,en does in a pregnancy following a ventral fixation. So opening into the uterus could be detected where the tubes had been cut. However, the location at both horns of the uterus were sewed over by redundant peritoneum. She made an uneventful recovery and on her follow-up examination on January 4, 1932, showed perineum and cervix normal, uterus anteverted, small, no cystocele. Abdominal sear healed; patient has no discomfort. In the first ease the uterus developed normally and pulled the bladder up with it. Consequently, there was no obstruction and the baby was born normally. In the second ease the uterus entirely developed posteriorly, causing a thick anterior portion, which almost entirely obstructed the birth canal, acting exactly like a fibroms which had developed in the lower anterior segment. DR. 0. PAUL HTJkII%TONE.-I nant after the Watkins’ interposition cases is whether or not the cervix interposition operation, the OS will
have observed two patients who became pregThe most important point in these operation. is amputated. If the cervix is amputated in the not diIate in k&or.
DR. HARBECK a low-flap cesaree.n
have seen only it was not possible
HALSTEAD.-I section because
one of these cases and to do anything else.
we did
DR. ROBERT T. FRANIG-The thing that strikes me most is the question of the technic in sterilizing these patients at the time. In my own experience, which covers quite a large series of cases, probably over 500, I have noted only one pregnancy after ligation of the tubes. I lay great stress upon not peritonealizing these two transected ends in tying them with a single ligature, tying over the loop, first to one side and then to the other. I transect them with the scissors and take great care to see that the openings are parallel to each other and not peritonealized, because should reestablishment of the lumen occur the likelihood of the ovum finding the second entrance is much reduced. On the contrary, if a normal tube, just like a normal vas deferens, is buried after transection in a connective tissue sheath, the likelihood of reestablishment of continuity is greatly increased. DR. ELIOT BISHOP.-The only thing I want to emphasize, as I have many times before, is that the actual sterilization is done by peritonealization, and not by artificial blocking. We have had no pregnancies follow this theory and pr&,iee of sterilization. About three years ago we collected over 100 cases and have had a number of additional cases sinoe then. We cut off a loop of each tube over catgut ligature and leave the two ends parallel, as Dr. Frank mentioned. The ends slowly pull apart after peritoneslization, which occurs in twenty-four to forty-eight hours, We have had the opportunity of opening two or three abdomens and have been able to demonstrate this. who
DR. ALFRED C. BECK-I had had an interposit.ion
recall operation
some years ago and amputation
treating a pregnant woman of the cervix by Dr. Polak.
NEW
YORK
OBSTETRICAL
945
SOCIETY
I do not recall whether he sterilized her or not; probably he did tie off the tubes. In that case I pulled a foot through the cervix, although it was very difficult to reach. Finally, the cervix dilated and a living child was delivered spontaneously by the breech. DR. RALPH M. BEACH.-1 would like to report a case of interposition during the childbearing period by Dr. Polak at the Jewish Hospital. At about the third or fourth month this woman developed a very marked elevation of the bladder, elongation of the urethra, marked clouding of the urine, distortion of the ureters, bilateral hydronephrosis, which was followed by retention, very marked toxemia, and jaundice. When she was brought to the hospital she was very sick. We emptied the uterus at this time, very easily, by an anterior hysterotomy. There being no bladder in front of the uterus, it was a very simple procedure. Following that the patient made a very rapid recovery. DR. RALPH A. HURD.-Sterilization of women in the childbearing period when an interposition operation is done, should always be preceded by curetting. In my case the patient menstruated about the middle of May and I operated upon her in the Woman’s Hospital the first week in June. I took great care to insure her against future pregnancies, but rather inadvertently neglected to euret the uterus. It seemed that she was pregnant at that time; she became pregnant between her last menstruation and her admission to the hospital, and she went on almost to term. I suspected a low implantation of the placenta, although I was never able to prove it on account of the great difticulty of examination. I did a cesarean section and she had a live baby five weeks from term. I think the aterilization has been well done because she has not become pregnant again. The tubes were apparently occluded completely and the two cut ends were sep arated and closed, or peritonealized thoroughly. I had to make the incision way up on the fundus, practically on the posterior wall of the uterus. The bladder was drawn up to the top. DR. BENJAMIN have been avoided
had
P. WATSON.--1 interposition
not
believe been
that done.
all of these complications could I regard it as a bad operation.
DR. CARL H. ILL.-1 did not operate originally on either one of these cases. They were referred to me for care during pregnancy. Both patients were Catholics, they would not consent to interruption of pregnancy, there was nothing else to do and, so, I had to let them go through with it. It so happened that both these cases were done by Edward Ill, and in going over his records with him I found that he has done almost 600 interposition operations. He has a very careful follow-up sysHe tem and these are the only cases that he had that have ever become pregnant. has used this method of sterilization, he tells me, for the last twenty years.
DR. JOHN J.
MADDEN
Calcium and Viosterol DR.
VICTOR
JOHN
(by invitation)
(by invitation) read in Pregnancy.
HARDING
presented
emias of Later Pregnancy.
a paper
entitled
!l’he
R3le of
DR. H. B. VAN M~YCK, of Toronto, Ont., a paper entitled Researches on the Tox(For original article see page 820.)
AND
DISCUSSION DR. H. B. VAN WYCK.-One of the striking things about the toxemia5 of pregnancy has always seemed to me to be the extreme number of varying types with a certain common association, and I feel that that has been too little taken account of in all etiologie discussions. We see that factor, too, in the diftieulty that has been