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Uchida tubal sterilization failure: A report of four cases
116
Communications
September 1, 197X Am. J. <)bster. Gynecol.
in brief
saturation. In the next few hours the respiratory rate decreased to 18 per minute. Over the next four hours the patient gradually improved symptomatically and the blood pressure returned to base-line values. Due to urinary retention six hours post partum, a Foley catheter was inserted with return of 200 ml of “cola-colored” urine which was 4+ positive for free hemoglobin on the dipstick. Microscopic examination of this urine revealed many hemoglobin granular casts and many crenated red blood cells. Laboratory values at this time were: white blood cell count, 19,400 per cubic millimeter; hemoglobin, 11.2 Gm. per 100 ml.; hematocrit, 35.5 vol. per 100 ml., prothrombin and partial thromboplastin time, within normal limits; fibrinogen, 250 mg. per deciliter; platelets, 290,000 per cubic millimeter; blood urea nitrogen, 8 mg. per deciliter. Because of a suspected amniotic fluid pulmonary embolus, a lung scan was obtained and showed a right apical wedge cut. Seven hours post partum temperature was 98.1” F.; arterial blood gases values were normal. At this time the urine was grossly clear and microscopic examination showed no casts and no red blood cells. Microscopic examination of a peripheral smear showed some fragmented red blood cells and some immature reticulocytes. Serum bilirubin was 0.4 mg. per 100 ml. Coombs test, direct and indirect, was negative. The patient became totally asymptomatic eight hours post panum and remained asymptomatic throughout the remainder of her hospilal course. A repeat lung scan three days post panum showed a persistent right apical defect. The infant’s blood type was B, Rh positive; the mother’s, type 0, Rh positive. The infant’s hematocrit was 61 vol. per 100 ml. Analysis of the mother’s anti-B titer predelivery was 1: 256. Five days post partum the titer was 1: 5 12. Twenty-
three days post partum the titer was 1: 2,048. Also the IgG anti-B titer of 1: 2 five days post partum rose to 1: 64 in the specimen three weeks post partum. A Fetaldex* stain of the maternal blood on the fifth day post partum revealed a few
circulating fetal red blood cells. The fetal/adult ratio was l/40,000.
red blood cell
If a significant fetal-maternal hemorrhage were occur into the circulation of an A-B-O-incompatible
renal
Bowman’
failure, presented
could
be explained.
a case
or fetomaternal
Any
transfusion
incompatible
blood
could
*Ortho
Diagnostics,
Inc.,
greater
than
Samet
and
A-B-O
in-
10 ml.
cause the full-blown
Raritan,
New Jersey.
Uchida tubal sterilization faikm: A report of four cases THOMAS
J. C.
BENEDETTI, MILLER.
M.D M.D.
to
compatibility, associated with an episode of post parturn hemoglobinemia and hemoglobinuria in a mother with type 0 blood and an infant with type B blood. The mother developed both consumptive coagulopathy and acute tubular necrosis. Six hours post partum the maternal serum showed an anti-B titer of saline agglutinin of 1: 4 compared to a titer of 1 : 2,048 in the maternal sample six weeks post partum. In our patient, the neonatal hematocrit of 61 vol. per 100 ml. indicates that the volume of the fetal-tomaternal hemorrhage was small. In general, the intensity of the hemolytic process dictates the symptoms and complications.
REFERENCES 1. Samet, S., and Bowman, H. S.: Fetomaternal ABO incompatibility: Intravascular hemolysis, fetal hemoglobinemia, and fibrinogenopenia in maternal circulation, AM. J. OBSTET. GYNECOL. 81: 49, 1961. 2. Renaer, M., Van DePutte, I., and Vermylen, C.: Massive fete-maternal hemorrhage as a cause of perinatal mortality and morbidity, Eur. J. Obstet. Gynecol. Reprod. Biol. 6: 125, 1976.
FRANK
mother, the signs and symptoms of’ an incompatible transfusion, such as fever, chills, and symptoms of hemolysis with intravascular coagulation and defibrination, followed by hemorrhagic diathesis and possible
acute
drome. Renaer and associate9 indicated that amniout fluid embolism is often suspected when the symptoms of severe hemolytic transfusion reaction are present.* Our patient had an initial diagnosis of amniotic fluid embolism. However, the subsequent hemoglobinnria. clinical course, and gradual rise in the anti-B titer over the post partum period argue against this diagnosis. The possibility of a pulmonary embolus was also entertained. We believe the lung scans were misleading. Another possible explanation of some of the signs and symptoms is the potential infusion of decidual material in the maternal circulation at the time of exploration of the uterus. The high concentration of prostaglandins found in the decidua may have resulted in many of the signs and symptoms presented by our patient. The case presented may well represent an example of an acute self-limited hemolytic transfusion reaction in an A-B-O-incompatible fetal-maternal unit.
of
syn-
Depart?rzent of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Los Angeles Couaty-Univevszty of Southern California Women’s Hospital, Los Angeles, Cal~fmia POSTPARTUM
TUBAL
Table I. Number time of cesarean
faiiureshave and Kroener
STERILIZATION
been associated with the Pomeroy,
Irving,
of tubal sterilizations by year
at
section
Procedure
1974
1975
1976
Total
Pomeroy Irving Uchida Kroener Unclassified
155 18 17 6 80
43 25 8 I 23
12 20 30 8 30
210 63 5.5 15 133
Total
276
100
100
476
Supported in part by National Institutes of Health Fellowship Training Grant No. HD 07086-01. Reprint requests: Dr. Thomas J. Benedetti, Department of Obstetrics and Gynecology, Room 5K-26, Los Angeles County-University of Southern California Women’sHospital, 1240 N. Mission Road, Los Angeles, California 90033. 0002-Y37A/78/01132-0116$00.?0/0
8 1978 T‘he C. V. Mosbv
GO.
Volume Number
132 1
Table
II. Summary
Communications
of four cases of Uchida
Pa-
tient
Procedure
J. L.
Cesarean Uchida
section and sterilization
s. j.
Cesarean section and
M. E.
Uchida sterilization Postpartum, Uchida
sterilization 0. G. Cesarean section and Uchida sterilization R = Right;
Date of procedure
tubal sterilization
in brief
117
failure
Procedure-pegnancy interval
Pathology
Follow-up
12176’
7 mo.
R tube, normal; L tube, no oviduct in specimen
Elective abortion at 10 weeks
7/76
2 mo.
R tube,
Delivered
2176
5 mo.
tubal epithelium seen R tube, normal; L tube,
5174
3 yr.
Specimens lost
normal;
L tube,
normal
no
at term. Bilateral fimbriectomy and tubal reiigation Delivered at term. Bilateral fimbriectomy and religation of tubes
Presently
32 weeks’
gestation
L = left.
techniques.’ No report exists that documents Uchida2 tubal sterilization failure. In this report, four known failures of the Uchida method in a three-yearinterval are documented. From January, 1974, through January, 1977, 476 tubal sterilizations have been done at the time of cesarean section at Los Angeles County-University of Southern California Women’s Hospital. A breakdown of the types of procedures performed can be found in Table I. The four surgeons associated with Uchida tubal sterilization failures were interviewed and the method of operation confirmed. Sterilizations were performed in a manner similar to that described by Uchida? The tube was grasped with Babcock clamps in two areas. Saline was used to inject the subserosa and dissect muscular tube from the serosa. The serosa was then incised and the tube isolated. It was ligated with 2-O silk proximally and distally and a portion excised. The proximal portion was then buried beneath the serosa and the peritoneal surface closed with 2-O chromic suture in a running fashion. The distal end of the tube was not buried beneath the serosa. Fimbriectomy was not done in any case. In Table II failures and significant data concerning each case are shown. The Uchida sterilization technique has been recently modified to include fimbriectomy.’ Elimination of repeat intrauterine and ectopic pregnancy was the reason given for this modification but neither has been previously reported as a complication of this procedure. Two of the sterilization failures in this report (in Patients J. L. and S. J.) are clearly failures of the surgeon.
In both instances, no portion of the left Fallopian tube was excised and the reason for subsequent pregnancy is obvious. One possible reason for failure to identify and excise the Fallopian tube was the use of saline without epinephrine. Dissection in the vascular mesosalpinx without use of epinephrine as described by Uchida may lead to problems with hemostasis. This can make identification of the Fallopian tubes more difficult and result in subsequent inadequate excision. The reason for failure in Patient M. F. was probably recanalization. In the initial pathologic specimen, both segments of excised Fallopian tubes demonstrated complete transection of the tube. Recanalization is implied as the reason for failure in Patient 0. G. as well. The three-year interval from operation to pregnancy without other contraception supports this supposition. However, no documentation from pathologic examination exists. Uchida tubal sterilization without fimbriectomy can result in failures secondary to both method failure and operator failure. We now perform fimbriectomies routinely as part of Uchida tubal sterilization. However, in our experience, surgically less complicated and less time-consuming procedures such as Pomeroy or Kroener procedures appear at least as effective as Uchida sterilization. REFERENCES 1. Pritchard, rics, ed. chap. 39, 2. Uchida, GYNECOL.
J. A., and MaiDonald, P. C.: Williams’ Obstet15, New York, 1976, Appleton-Century-Crofts, pp. 857-860. H.: Uchida tubal sterilization, AM. J. OBSTET. 121: 153, 1975.
Communications
September 1, 197X Am. J. <)bster. Gynecol.
in brief
saturation. In the next few hours the respiratory rate decreased to 18 per minute. Over the next four hours the patient gradually improved symptomatically and the blood pressure returned to base-line values. Due to urinary retention six hours post partum, a Foley catheter was inserted with return of 200 ml of “cola-colored” urine which was 4+ positive for free hemoglobin on the dipstick. Microscopic examination of this urine revealed many hemoglobin granular casts and many crenated red blood cells. Laboratory values at this time were: white blood cell count, 19,400 per cubic millimeter; hemoglobin, 11.2 Gm. per 100 ml.; hematocrit, 35.5 vol. per 100 ml., prothrombin and partial thromboplastin time, within normal limits; fibrinogen, 250 mg. per deciliter; platelets, 290,000 per cubic millimeter; blood urea nitrogen, 8 mg. per deciliter. Because of a suspected amniotic fluid pulmonary embolus, a lung scan was obtained and showed a right apical wedge cut. Seven hours post partum temperature was 98.1” F.; arterial blood gases values were normal. At this time the urine was grossly clear and microscopic examination showed no casts and no red blood cells. Microscopic examination of a peripheral smear showed some fragmented red blood cells and some immature reticulocytes. Serum bilirubin was 0.4 mg. per 100 ml. Coombs test, direct and indirect, was negative. The patient became totally asymptomatic eight hours post panum and remained asymptomatic throughout the remainder of her hospilal course. A repeat lung scan three days post panum showed a persistent right apical defect. The infant’s blood type was B, Rh positive; the mother’s, type 0, Rh positive. The infant’s hematocrit was 61 vol. per 100 ml. Analysis of the mother’s anti-B titer predelivery was 1: 256. Five days post partum the titer was 1: 5 12. Twenty-
three days post partum the titer was 1: 2,048. Also the IgG anti-B titer of 1: 2 five days post partum rose to 1: 64 in the specimen three weeks post partum. A Fetaldex* stain of the maternal blood on the fifth day post partum revealed a few
circulating fetal red blood cells. The fetal/adult ratio was l/40,000.
red blood cell
If a significant fetal-maternal hemorrhage were occur into the circulation of an A-B-O-incompatible
renal
Bowman’
failure, presented
could
be explained.
a case
or fetomaternal
Any
transfusion
incompatible
blood
could
*Ortho
Diagnostics,
Inc.,
greater
than
Samet
and
A-B-O
in-
10 ml.
cause the full-blown
Raritan,
New Jersey.
Uchida tubal sterilization faikm: A report of four cases THOMAS
J. C.
BENEDETTI, MILLER.
M.D M.D.
to
compatibility, associated with an episode of post parturn hemoglobinemia and hemoglobinuria in a mother with type 0 blood and an infant with type B blood. The mother developed both consumptive coagulopathy and acute tubular necrosis. Six hours post partum the maternal serum showed an anti-B titer of saline agglutinin of 1: 4 compared to a titer of 1 : 2,048 in the maternal sample six weeks post partum. In our patient, the neonatal hematocrit of 61 vol. per 100 ml. indicates that the volume of the fetal-tomaternal hemorrhage was small. In general, the intensity of the hemolytic process dictates the symptoms and complications.
REFERENCES 1. Samet, S., and Bowman, H. S.: Fetomaternal ABO incompatibility: Intravascular hemolysis, fetal hemoglobinemia, and fibrinogenopenia in maternal circulation, AM. J. OBSTET. GYNECOL. 81: 49, 1961. 2. Renaer, M., Van DePutte, I., and Vermylen, C.: Massive fete-maternal hemorrhage as a cause of perinatal mortality and morbidity, Eur. J. Obstet. Gynecol. Reprod. Biol. 6: 125, 1976.
FRANK
mother, the signs and symptoms of’ an incompatible transfusion, such as fever, chills, and symptoms of hemolysis with intravascular coagulation and defibrination, followed by hemorrhagic diathesis and possible
acute
drome. Renaer and associate9 indicated that amniout fluid embolism is often suspected when the symptoms of severe hemolytic transfusion reaction are present.* Our patient had an initial diagnosis of amniotic fluid embolism. However, the subsequent hemoglobinnria. clinical course, and gradual rise in the anti-B titer over the post partum period argue against this diagnosis. The possibility of a pulmonary embolus was also entertained. We believe the lung scans were misleading. Another possible explanation of some of the signs and symptoms is the potential infusion of decidual material in the maternal circulation at the time of exploration of the uterus. The high concentration of prostaglandins found in the decidua may have resulted in many of the signs and symptoms presented by our patient. The case presented may well represent an example of an acute self-limited hemolytic transfusion reaction in an A-B-O-incompatible fetal-maternal unit.
of
syn-
Depart?rzent of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Los Angeles Couaty-Univevszty of Southern California Women’s Hospital, Los Angeles, Cal~fmia POSTPARTUM
TUBAL
Table I. Number time of cesarean
faiiureshave and Kroener
STERILIZATION
been associated with the Pomeroy,
Irving,
of tubal sterilizations by year
at
section
Procedure
1974
1975
1976
Total
Pomeroy Irving Uchida Kroener Unclassified
155 18 17 6 80
43 25 8 I 23
12 20 30 8 30
210 63 5.5 15 133
Total
276
100
100
476
Supported in part by National Institutes of Health Fellowship Training Grant No. HD 07086-01. Reprint requests: Dr. Thomas J. Benedetti, Department of Obstetrics and Gynecology, Room 5K-26, Los Angeles County-University of Southern California Women’sHospital, 1240 N. Mission Road, Los Angeles, California 90033. 0002-Y37A/78/01132-0116$00.?0/0
8 1978 T‘he C. V. Mosbv
GO.
Volume Number
132 1
Table
II. Summary
Communications
of four cases of Uchida
Pa-
tient
Procedure
J. L.
Cesarean Uchida
section and sterilization
s. j.
Cesarean section and
M. E.
Uchida sterilization Postpartum, Uchida
sterilization 0. G. Cesarean section and Uchida sterilization R = Right;
Date of procedure
tubal sterilization
in brief
117
failure
Procedure-pegnancy interval
Pathology
Follow-up
12176’
7 mo.
R tube, normal; L tube, no oviduct in specimen
Elective abortion at 10 weeks
7/76
2 mo.
R tube,
Delivered
2176
5 mo.
tubal epithelium seen R tube, normal; L tube,
5174
3 yr.
Specimens lost
normal;
L tube,
normal
no
at term. Bilateral fimbriectomy and tubal reiigation Delivered at term. Bilateral fimbriectomy and religation of tubes
Presently
32 weeks’
gestation
L = left.
techniques.’ No report exists that documents Uchida2 tubal sterilization failure. In this report, four known failures of the Uchida method in a three-yearinterval are documented. From January, 1974, through January, 1977, 476 tubal sterilizations have been done at the time of cesarean section at Los Angeles County-University of Southern California Women’s Hospital. A breakdown of the types of procedures performed can be found in Table I. The four surgeons associated with Uchida tubal sterilization failures were interviewed and the method of operation confirmed. Sterilizations were performed in a manner similar to that described by Uchida? The tube was grasped with Babcock clamps in two areas. Saline was used to inject the subserosa and dissect muscular tube from the serosa. The serosa was then incised and the tube isolated. It was ligated with 2-O silk proximally and distally and a portion excised. The proximal portion was then buried beneath the serosa and the peritoneal surface closed with 2-O chromic suture in a running fashion. The distal end of the tube was not buried beneath the serosa. Fimbriectomy was not done in any case. In Table II failures and significant data concerning each case are shown. The Uchida sterilization technique has been recently modified to include fimbriectomy.’ Elimination of repeat intrauterine and ectopic pregnancy was the reason given for this modification but neither has been previously reported as a complication of this procedure. Two of the sterilization failures in this report (in Patients J. L. and S. J.) are clearly failures of the surgeon.
In both instances, no portion of the left Fallopian tube was excised and the reason for subsequent pregnancy is obvious. One possible reason for failure to identify and excise the Fallopian tube was the use of saline without epinephrine. Dissection in the vascular mesosalpinx without use of epinephrine as described by Uchida may lead to problems with hemostasis. This can make identification of the Fallopian tubes more difficult and result in subsequent inadequate excision. The reason for failure in Patient M. F. was probably recanalization. In the initial pathologic specimen, both segments of excised Fallopian tubes demonstrated complete transection of the tube. Recanalization is implied as the reason for failure in Patient 0. G. as well. The three-year interval from operation to pregnancy without other contraception supports this supposition. However, no documentation from pathologic examination exists. Uchida tubal sterilization without fimbriectomy can result in failures secondary to both method failure and operator failure. We now perform fimbriectomies routinely as part of Uchida tubal sterilization. However, in our experience, surgically less complicated and less time-consuming procedures such as Pomeroy or Kroener procedures appear at least as effective as Uchida sterilization. REFERENCES 1. Pritchard, rics, ed. chap. 39, 2. Uchida, GYNECOL.
J. A., and MaiDonald, P. C.: Williams’ Obstet15, New York, 1976, Appleton-Century-Crofts, pp. 857-860. H.: Uchida tubal sterilization, AM. J. OBSTET. 121: 153, 1975.