Uterus Didelphys Complicating Pregnancy

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AMEIUCAN .JOURNAL OF OBH'fETRICS ..\:'>ill OYNECOLOOY

The pregnant fundus was moderately asymmetrical with a bulging toward the upper left pole and a flattening of the entire mesial side. An incision was made in what appeared to be the proper location, and a viable, normal female infant, weighing li pounds, was extracted. The placenta came away easily and the uterine wound was- ready for elost;r<·. ThiF proved not as easy as at first anticipated, aii the flattened mesial fundai wall proved to be very thin indeed. Even in its eontracted state it was little th i"k•'r than itPavy r·nnlhoard. while the right side Fhowed thf• usual tiRsue depth. . . The uterine wall being dosed, it waR now possible to inspect the peh·is in detaiL Fol· lowing the mesial border of the incised uteruf; downward, our cmue to a shallow depression at the level of the cervix, and proceeding laterally to the left, encountered the second uterine body lying transversely in the pelvis. This had the appearance of a normal fundus as to size and consistency, but had only one round ligamPnt and only onp tube and ovary, which arose in proper position in the left upper cornu. 1'he right side of this uterus was also slightly flattened and showed no appendages. The fundus which had contained the child also had only one tube and ovary and one round ligament. 'l'hese arose from the right uppt>r margin and were normal. There were no adnexa on the left side of this organ. ·with the uterine musculature thinned out to so disquieting a degree, a condition that could not be discovered except by direct observation, and with a second uterine body blocking the pelvis, which could only be palpated early in pregnancy, a complete and accurate diagnosis is impossible. Confronted with the ever-present danger of hemorrhage or nterint> rupture, it would seem that operation is indicated under all romlitions. 501

METROPOJ.JTAN BUILDING.

UTB:&US DIDBLPBYS OHIPLICATlNG PBBQJfUOY IRWIN

K. W.

T.

CRAIG, LT. CoMDR., MEDICAL CoRPS, USNR, AND

ScHENK, LT. CoMDR., MEDICAL CoRPs, USNR, FoRT h<\UDERDALE, FLA.

(From the Out-Patient Department, U. S. Naval Air Station) CASE of pregnancy in uterus didelphys with small myomas in the nongravid uterus, delivered by cesarean section, is presented herewith. Mrs. \V. P., aged 26 years, gravida i, para O, was 1irst seen in the outpatient department, June 10, 1944. Her last period was April 13, 1944, and she had slight nausea with occasional vomiting as her chief complaint. Her past history was negative for all diseases except measles, chickenpox, and mumps. She had never had any operations. Menstrual history showed menarche at 12 years of age, and periods had been uninterrupted until her present pregnancy. The interval has been 30 to 32 days, with a heavy six-day flow. There has been no intermenstrual bleeding, and dysmenorrhea has never caused the patient concern. Physical examination revealed a well-developed, well-nourished white woman, weighing 127 pounds. Blood pressure, 96/70. Urine showed a trace of albumin. Hemoglobin, 79 per cent; red blood cells, 4,460,000-; Kahn test, negative. On pelvic examination a vaginal septum was found extending the full length of the vagina, dividing this structure into two halves. The right half admitted two :lingers easily and the left half admitted two fingers with difficulty, indicating that coitus had been practiced chiefly, if not entirely, on the right side of the septum. Speculum examination revealed two normal-sized cervices, one in each vaginal canal, and there was no attachment of the septum to either cervix. Two separate fundi were identified on bimanual examination, with the right fundus about twice the size of the one on the left. It was felt that we were dealing with a case of pregnancy in the -right side of a uterus didelphys. The course of pregnancy was uneventful except for a Tric;homonas vaginaJ.i.s vaginitis which was found in the last month of pregnancy and was untreated at that time. X-ray of the abdomen on .Tan. 13, 1945, showed a full-term fetus in a right sacroanterior position with the breech not engaged.

A

CRAIG AND SCHENK:

UTERUS DIDELPHYS COMPLICATING PREGNANCY

557

Onset of labor, January 28, was marked by the spontaneous rupture of the membranes with irregular contractions beginning shortly thereafter. The patient was admitted to the hospital and a rectal examination showed the breech fairly high, cervix about 2 em. dilated, and contractions every three minutes, lasting twenty-five seconds and of poor quality. Pains continued irregularly throughout the night. By noon the next day the patient showed signs of exhaustion and the cervix was only 2¥.2 fingers dilated. A foot could be palpated through the external os on rectal examination. Contractions seemed to involve portions of the uterus when they occurred and it was felt that uterine contractions were not sufficient to produce complete dilatation or expulsion of the fetus. Temperature had risen to 99.8° F., and the pulse rate was 100. She was given 1,000 c.c. of 5 per cent dextrose in normal saline and prepared for cesarean section twenty-one hours after the onset of labor. A low flap section was done by one of us (I. T. C.), and a 6-pound 12-ounce female infant was delivered by breech extraction. After closure of the uterus the pelvis was explored and two complete and distinct uteri were found. A normal tube and ovary arose from the lateral cornu of each uterus. The left, nongravid uterus was enlarged nearly two and onehalf times and had a small subserosa! fibroid on both the anterior and posterior surfaces. 'rhe relationship of these two uteri is illustrated (Fig. 1).

_ Fig. 1.-Findings on laparotomy. The breech is presenting as a single footling in the rtght uterus. The left uterus is enlarged and contains small myomas, one of which is visible on the anterior surface. The patient was returned to her room and given a transfusion of 250 c.c. of citrated blood. Postoperative condition was good. Abdominal distention developed and persisted for several days but was relieved by negative suction, morphine, and a light cradle to the abdomen. Her nurses were cautioned to watch for the passage of the decidual cast from the opposite side with her lochia, but if it ever passed it was not identified as such. The patient developed a pericarditis with effusion on the fifth postoperative day, but she responded well to 900,000 units of penicillin, calcium, oxygen therapy and 500 c.c. of citrated blood, and the heart shadow slowly returned to normal. An increase in the cardiac dullness to percussion and diminished breath sounds anteriorly were found on physical exam-

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AMgRICAN ,JOURXAL OF OBSTETRICS AK!l OYNECOLOGY

ination and an electrocardiogram showed myocardial damagP. 'rhe patient was disdmrged from the hospital on the twenty-sixth postoperative day. A postpartum check on March 14 slHlWPd the abdominal scar well healed. Both ut,•ri were about one and one-half times enlargt>s of the urinary tract existed, but the only abnormal :finding was dilatation of the right nrPter, a condition eommonly encountered in pregn:mcy and in thP early postp:utum perioL1.

ACUTE DIVERTICULITIS OF THE SKDIOID l1f PBB&IfAlfCY M. D. ScHNALL, M.D., NEw YoRK, N.Y., L. E. PHANEUF, M.D., Sc.D., AND J. F. CoNWAY, M.D., BosToN, MAss. (From the Department of Obstetrics and Gynecology, Carney Hospital)

D

IVERTICULITIS is a condition occurring not uncommonly in the female, and some excellent papers have been written on this complication. 1 ' 2 However, a review of the literature for the past forty years with the aid of the American College of Surgeons' Library Staff has not revealed the description of a case of acute diverticulitis occurring in pregnancy. It is possible that a number of such cases go undiagnosed and for this reason we point out that in gravid women complaining of left lower quadrant pain, the differential diagnosis should include acute diverticulitis. Following is a case of acute diverticulitis of the sigmoid with abscess formation and spontaneous resolution in pregnancy, labor, and in the puerperium. The patient, D. M., a 31-year-old primigravida, entered the Carney Hospital on May 22, 1944, complaining of pain in the left lower quadrant of three days' duration. There were no familial tendencies other than that the father died of carcinoma of the bowel. She had no previous illnesses and no operations. except tonsillectomy as a child. The systemie review was unusual only in that there had been a lifelong tendency from early childhood toward severe constipation. Occasionally she had gone up to eight days without a bowel movement, and then hard fecal masses were passed. The menarche was at 18 years and the periods were irregular, coming at one- to fourmonth intervals. The last menstrual period was on July 23, 1943. The prenatal examinations revealed no pelvic pathology, and the pregnancy, excepting constipation, was free of untoward signs and symptoms except for constipation. While turning over in bed on May 19, 1944, at 11 P.M., she suddenly experienced a sharp nonradiating pain jnst medial to the left anterior superior iliac spine, lasting only for a few seconds. Her condition was unchanged until 9 A.M. next day when she felt faint and had an aching sensation diffusely throughout the left lower quadrant. During the next three days pains occurred in the left flank and left lower quadrant every one and one-half to three hours, lasting one-half hour; they were dull at the onset but gradually became sharp. During thi8 time the patient was anoretic; there had been no bowel movement for three days. At the time of admission to the Carney Hospital on May 22, the physical examination revealed a well-developed and well-nourished white woman somewhat restless in bed but not complaining of pain. The temperature was 98.6° P. pulse 8G, respirations 18, and blood pressure 120/60. There were psoriatic lesions over the chest, back, and arms. 'rhe head, ears, eyes, nose, and throat appeared normal. Heart and lungs were normal. 'l'he breasts were free of masses. The upper abdomen was soft and slightly distended. The liver, spleen, and kidneys could not be palpated. The uterus was enlarged to three fingerbreadths above the umbilicus; the fetus was found to be with the left occiput anterior, the fetal heart tones being 138 and of good quality. Moderate tenderness and spasm were found in .the left lower quadrant and flank. Rectal examination disclosed the head well engaged, cervix soft ann slightly taken up. Except for lesions of psoriasis the extremities were not remarkablH.