Uterine Apoplexy Following an Elective Second Cesarean Section*

UTERINE APOPLEXY FOLLOWING AN ELECTIVE· SECO:RD OBSAll.EAN SECTION* STA::'\LEY

C.

HAU~,

(Fron• the Departmen.t of

M.D., F.A.C.S.,

Obstetric~e

BROOKLY:-.1,

a.nd Gynecology,

N. Y.

Methodi.~t

Hwpi.tcd)

HAT uteroplaeental apoplexy not an infrequent condition, is shown by the fact that in fom preceding the appearance of T Williams' article in 1915, twenty such cases had heen described and i::-;

~·ears

Portes was able to collect 73 cases in 192a. In 1921, Wilson reported a series of 69 cases, 46 of which were observed at laparotomy or autopsy. In 55 cases, in which something definite is said regarding the presence or absence of clinical evidence of toxemia, the rondition of the patient indicated its absence in seven ea:;;;es. Thore wt•re 3H maternal deaths in the 69 cases-a mortality rate for the whole sNies oJ' 55 per cent. The :five babies which survived were all delivered bv resarean section. The hypothesis which Wilson advan<"es is that ~ hemorrhagic toxin is liberated by the placenta, which produees its maximum effect locally, and secondarily produces manifestations oJ' a general toxemia. The case of uterine apoplexy which I am reporting iR unique foT the following reasons: First, tht' uturine apoplexy followed an elective secondary cesarean section in a normal patient. Second, there was no evidence of any premature separation of the placenta, and a microscopic section from the placental site did not show hemorrhage. Mrs. E. C., Grav. ii, para i, aged 31 ,\·cant Putient alwa.vs well, except for appendectomy in 1938. Her first pregnancy was in ,July, Hl40. This was uneventful, except that the patient was due on ,June 20th, and did not enter the hospital until she was four weeks overdue, at which time she had a transverse presentation. A low classical cesarean section was performed under gas oxygen and ether. The baby was abnormal and lived only a few minutes. The post-partum x-ray diagnosis on the baby wa:;; aehondroplasia. The autopsy diagnosis was chondrodystrophia ft'tallH. The uterine bleeding at the time of the cesarean section wa;.; moderate and controlled by intrauterine pituitrin and intravenous ergotrate. The patient became pregnant again in July, 1!)41, being due April 26, 1942. She had a normal blood pressure and urine throughout her prenatal course. She was admitted to the hospital on April 12th, two weeks before term beeausP of pain in the lower abdomen. Examination at that time showed either a small incisional hnmia or a Yery thin uterine scar, which was slightly tender. There were no uterine contractions, the uterus was soft, membranes intact, no vaginal bleeding, vertex presentation. The baby seemed to be average size. Blood pressure was 110/84, temperature 98.4° F., pulse 88, urine negative, hemoglobin 85 1wr cent, 4,200,000 red eells. Patient was given morphine and blood taken for typing anrl an x-ray of the abdomen showed no abnormality of the fetus. The morphine relieved the lower abdominal pain and there were no signs of labor or recurrence of pain. A low classical secondary cesarean section was performed the next morning, under spinal anesthesia. using 15 mg. of pontocaine and 50 •Presented before the Associated Physicians of Long Isla.nu, at Methodist Hospital. January 30. 1943. and the Brooklyn Gynecological Society. March 5, 194~.

734

HALL:

-ion

UTEBINE APOPLEXY For..LOWlNG ·~ SE£T!ON

mf,, oi' prooaille.. ;~b:US for the secti
785

were a· previous cesai'ean

0»~~ w!ll &$. ·f~~~:. T:be. ~ ..in~ was +exeifJed. \. Sevetal areas .in t~ fascia haa aepara.ted f~lti:nt~Jl(f the previ:oWJ opemtion. Th~ uterine sear was well healed except in one m:nall area where it was less

than a centimeter thick. The uterine incision was made in the region of .the old scar. The membranes were ruptured at this time; a normal baby girl was extracted fr.om ~J;n L.O.T. position, weighing 6 pounds 5 ounces. The uterus remained contracted an,d there was no bleeding until the placenta was removed and then only a moderate amount. One C.C.' of pituitrin was injected into two different areas of the uterus. The uterus was closed and the incisional hernia repaired. Duration of the operation wa.S 55 minutes. · During the closure, the anesthetist reported. that the patient's blood pressure had dropped to 80/60 and that the pulse had increased to 140. The patient was given ephedrin and 500 c.c. of plasma and kept on the operating table. for further obset:vation. She continued to remain in a shocked condition and so continuous plasma with· adrenal cortex was given and arrangements were made for a blood transfusion. The anesthetist did not :feel that the condition was due to spinal shock, because of its delayed appearance and. because the spinal anesthesia was wearing oft'. and never did reaeh a high level. A medical consultation was obtained but no evideace. of chest pathology was found. ;Frequent examination of the abdomen did not reveal any accumulation of ftuid. The uterus seemed to be enla,rging. There W&$ normal post-partum vaginal bleedilig-.a small amount could· be expressed from the uterus. There were no clots. About three hours later· the patient was still on the operating table in a shocked condition, with a blood pressure· of 60/40 and pulse of 140. The abdominal.qressing was removed and found to be stained with serous sanguineous .1ll;tid, bUt there was no .evidence of any hematoma· of the wound or a'b4otniB8J. W1tll. · Because of the continued shook alld no hnprovement and the pallid appeaMnce of the patient, it was .decided there must be internal bleeding, so an exploration through the abdomil141 incision was perform~d. At this :time, the blood pressure coul" not" be ob~ned. There was no pulse and the heart rate was about 160; C~tint;Wus plasma and bloOd were being given. When t}}e incision was opened there wa,S. considerable oozw.g from ·all .sur.f.aees...• h.e.... ~. :. ito .. ile.al ea.vity eo.ntain~ .a . considera.ble amount of a thin bl®dy ·. :O.ui:d &lld · there was no eVIdence of bleeding from the intact uteiine incision> ·At this point the patient vomited several ounces of bright red blood. The uterus was enl11tged to more than twiee normal pQ.St-par~ size and mt.s purple blue in color. The wall was. soft and; bog~ a~d WOOn at attell}pt was made to remove it through the abdoriwialincision,.$vetal holes were made in the. posterior wall of the fundus with the· e:Uinining fi.Dgers. These areas bled considerably. A diagn~is of· uterine apoplexy was made and an immediate supercervical hysterectomy p~rformed. There was _considerable oozing from raw surfaces which was controlled with suture ligatures. T;he patient received altogether 1,75Q .c.c. of 25 per cent glucose. 7 c.e. of adrenal cortex solutioi;t. The patient was on the operating table from 9 A..M:. 'to 5 t";M. that afternoon, at.·wbieh time she was very mneh improV!ed, with a blOOd p~ure. of}00/60 .fltn(l, a pulse of 120. She received anothe.r 500 c..c. of· blood ·lJPOn · re~:rning to her room. She. had an uneventfni recovery, being discharged home, with the baby, on the nineteenth pos.toperative day. Examinations since have found her to be perfectly normal. T.·

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AMERICAN. JOUR~AL OF OBSTETRICS AND GYNECOI,OGY

Gross Pathological Examination of the Placenta and Uterus The placenta showed no pathology. Examination of the uterus showed an incision 12 em. long. The edges of the incision were closely approximated with sutures. No fluid or clotted blood was present in the wound. The entire serosal surface of the uterus was a deep purplish-blue in color. Throughout the uterus the myometrium was deep red in color and appeared to be extensively infiltrated with blood. 'Phere ,.,·ere a Jew small dots adherent to th e placental ~ite on the posterior surfac•e of the utcrws.

Fig. 1.--Piacental s ite- D ecidua and e ndometrium ot' pregnancy. hemorrhage in my o metrium. X 7fl.

::-.ote a.bsence fJf

Fig. 2.-Section from outer uterine wall in the fundus. Muscle fibers widely separated by hemorrhage and edema. X75.

Microscopic examination of a section from the fundus showed muscle fibers hypertrophied and some degenerated. Single muscle fibers were separated from each other by edema and extravasated red blood cells. A section from the wall of the placental site showed a layer of blood on the inner surface, beneath this a thin zone of desidua and endorne-

HALL :

UTERINE APOPLEXY FOLLOWING CESAREAN SECTION

737

trium of pregnancy. The muscle fibers were hypertrophied. There was no blood in the myometrium of that area. A section taken from the lower uterine segment showed edema and hemorrhage, but not as marked as at the fundus. Pathological Diagnosis: Apoplexy of the uterus.

Comment In reviewing, one case reported by Snowden showed bleeding from the abdominal incision for several days following a cesarean section in a case of uteroplacental apoplexy with nephritic toxemia. There were numerous cases which had bleeding from other organs, and in some the intraperitoneal fluid was mostly of a serous nature. Blood examination of the patient before and after the operation did not reveal any dyscrasia. It seems that the uterine apoplexy in this case might have been caused by a placental toxin as described by Wilson, because of the bleeding from the abdominal incision, the vomiting of blood, the serous sanguineous fluid in the abdomen and the excessive bleeding at the time of the hysterectomy.

Conclusions 1. A review of the literature fails to reveal a similar case of uterine apoplexy. 2. This case report seems to bear out the theory that a hemorrhagic toxin may be responsible for uterine apoplexy and bleeding in other parts of the body. ' 3. Uterine apoplexy should be considered in patients going into marked shock following a cesarean section. 4. This case shows that a patient in extreme shock from uterine apoplexy with an unobtainable blood pressure, will withstand a hysterectomy if proper supplementary treatment is given by plasma and blood during the operation.

References 1. Stander, N.J.: Williams Obstetrics, ed. 8, New York, 1941, D. Appleton-Century

2. 3. 4. 5. 6.

Co., p. 1049. Williams, J. W.: Surg., Gynec. and Obst. 21, No. 5: 541, 1915. Lee, Gordon: J. Obst. & Gynaec. Brit. Emp. 28: 69, 1921. Wilson, P.: Surg., Gynec. & Obst. 34: 57, 1922. Snowden, E.: J.A.M.A. 36: 1066, 1921. Portes, L.: Gynec. et Obst. 7: 56, 1923. 34

~SPEOT

PARK WEST