Volume 125 Number2
The purpose of this presentation is to stress the role of operative technique in tubal prolapse, to describe a simple method for correcting the complication, and to add an unusual sign not previously mentioned in association with such cases. A 22.year-old woman, para 1-0-O-l. underwent vaginal hysterectomy following a diagnosis of carcinoma in situ of the cervix. The edge of the vaginal cuff was sutured with continuous chromic catgut. Angle sutures, including the anterior and posterior vaginal epithelium, peritoneum, and the cardinal, uterosacral, and round ligaments, were placed. The vaginal epithelium was further closed with a figure-ofeight suture. A medium Penrose drain was left in the cuff. Left lower quandrant discomfort was experienced with mobilization postoperatively but did not become severe until coitus was resumed. Four weeks after surgery, a clear watery vaginal discharge began and required the use of a perineal pad. About the same time, she noted the onset of diarrhea as often as three times daily. Coitus was associated with increased left lower quandrant pain, nausea, and defecation. Initially defecation occurred during coitus (with the patient unaware) but later it followed intercourse. The patient was examined by her physician, who observed “granulation tissue” at the vault 4 weeks postoperatively. Initial treatment with silver nitrate and later cryosurgery were ineffective. Eight weeks after surgery, biopsy of the “granulation tissue” was reported as endometriosis of the vaginal wall. Medroxyprogesterone acetate suspension (DepoProvera) was then given. About 4 months postoperatively, the author biopsied the lesiop. A report of a portion of the Fallopian tube with infection was returned. After tetracycline therapy, the lower abdo,minal pain subsided. The prolapsed Fallopian tube
then removed under general anesthesia by separating the tube from the vaginal cuff and pulling forward before amputation. The tube was easily separated from the cuff by spreading Metzenbaum scissors while pulling the tube by an attached suture. The vaginal vault healed and the patient’s symptoms disappeared. was
As occurred in some of the previously reported cases, the correct diagnosis was not made initially. Due to the marked inflammation which is usually present in the visiable portion of such a tube, a diagnosis of endometriosis was made. Cautery and cryosurgery were employed without success. Weeks later, the correct diagnosis was discovered and, after surgery the characteristic complaints of watery vaginal discharge and lower abdominal pain were relieved. The appreciation of dyspareunia in the left lower quadrant rather than vaginally suggests a prolapse of the left Fallopian tube. Pain from the Fallopian tube itself is referred to the lower abdominal wall on its respective side. Jeffcoate
abdominal viscera in that it is sensitive to touch, cutting, and crushing.’ An unusual sign present in this case was that of defecation during coitus or immediately thereafter. Whether this occurred 8s a result of the bowel being somewhat inflamed and hypersensitive because of its
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proximity to the inflamed Fallopian tube is not known. Semen might have leaked through or, with the loose peritoneal agglutination of the tube to the vaginal iault, around the tube,’ producing direct irritative stimulus on the bowel much as may take place in the uterus when semen is deposited directly within the intrauterine cavity. This sign also disappeared postoperatively. Rather than making an elliptical incision in the vaginal epithelium surrounding the vault defect, in this case, it was simpler and possibly less risky to apply traction to the tube by means of a well-anchored suture and separate the vault from the loosely agglutinated peritoneum of the tube with Metzenbaum scissors. This was easily accomplished permitting the tube to be tied high and excised followed by closure of the vault. As has been noted by others, prolapse of the Fallopian tube following vaginal or abdominal hysterectomy is probably much more common than the number
emphasizes the importance of careful closure of the vaginal vault. Factors which seem to favor tubal prolapse are sepsis, poor hemostasis, lack of separate closure of peritoneum and vagina, and the use of drains. Simple release of the agglutinated tubal peritoneum from the vault rather than surgical incision is suggested as perhaps a less risky alternative in some cases. A sign (defecation with coitus) not previously described as associated with vaginal prolapse of the Fallopian tube is reported. REFERENCES
1. Smout, C. F. V., Jacoby, F., and Lillie, F. W.: Gynaecological and Obstetrical Anatomy, ed. 4, Baltimore, 1969, The Williams & Wilkins Compahy, p. 339. 2. Tabrisky, J., Mallin, L. P., and Smith, J. A., III: Pneumoperitoneum after coitus, Obstet. Gynecol. 40: 2 18, 1972.
Fetal heart rate monitoring in pregnant patients undergoing surgery JONATHAN
Department of Anesthesiology, Yale University Medicine, New Haven, Connecticut
elective surgery can be postponed until after delivery, there are certain surgical conditions which are emergent and require operative intervention during pregnancy. The intraoperative management of these patients must include an anesthetic that insures
Reprint requests: Jonathan D. Katz, M.D., Anesthesiology, Yale University School of
Cedar St., New Haven, Connecticut 06510.
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Fig. 1. Serial samples of fetal heart rate: A and B, Baseline fetal heart at 140 beats per minute, with normal beat-to-beat variability. C, Fetal tachycardia and stabilization of the beat-to-beat interval at maternal PaOs = 56 torr. D, Following correction of maternal ventilation there is a return to baseline fetal heart rate and variability. E, Normal baseline postoperatively. optimal operating conditions, while protecting fetus from external influences which could place jeopardy. Recent advances in fetal physiology monitoring make such an anesthetic possible. purpose of this communication is to demonstrate potential value of the fetal heart rate monitor evaluation of fetal well-being during surgery.
the it in and The the for
In Case 1, a 17-year-old black multipara, 8 months pregnant, was admitted for evaluation and treatment of retina1 detachment of the right eye. Significant past medical history included hospitalization at age 19 months with paralytic poliomyelitis and meningitis. This resolved without residual deficiency. In 1971, at age I4 years, she had a saline-induced abortion in the first trimester of her first pregnancy. Physical examination on admission revealed a mildly retarded female. Vital signs were normal. Eye examination revealed a retinal detachment in the superior temporal quadrant. Her uterine fundus was 34 week size, and fetal heart sounds were audible at a rate of 140 beats per minute. She was premeditated with secobarbital (100 mg.), hydroxyzine (60 mg.), and atropine (0.5 mg.) intramuscularly. minutes prior to arrival in the operating room. An external fetal heart rate monitor was positioned prior to the induction of anesthesia. Initiation of anesthesia was accomplished with thiopental, 400 mg. intravenously. After induction, an intra-arterial canula was placed in the radial artery. Assisted ventilation via an endotracheal tube with 50 per cent N,O in oxygen and 1 per cent halothane was maintained throughout the surgical procedure. A retrobulbar block and field block with 16 cc. of 2 per cent lidocaine was administered. During the repair of the retinal detachment the blood pressure varied from 140195 to 95165 torr. The fetal heart rate varied from 130 to 160 beats per minute (Fig. 1). The duration of anesthesia was 2 hours 30 minutes. She was returned to the recovery room in satisfactory condition, where fetal monitoring was continued. Fetal heart rate and maternal vita1 signs were stable throughout the recovery room period.
In Case 2, an IX-year-old primipara. 6 months pregnant, was admitted for treatment of a detached retina of the right eye. On physical examination, she was very anxious. Vital signs were normal. Retinal examination revealed a bullous inferior detachment. The uterine fundus was consistent with that of a sixth-month pregnancy. Fetal heart rate was 130 beats per minute. She was premeditated with secobarbital (100 mg.) intramuscularly 60 minutes prior to arrival in the operating room. An external fetal heart monitor was positioned prior to the start of anesthesia. After induction with thiopental, 300 mg. intravenously, anesthesia was maintained with 50 per cent NzO in oxygen and 1 per cent halothane by assisted ventilation via endotracheal tube. An intra-arterial catheter was placed in the right dorsal pedal artery. A retinal detachment repair was accomplished. The patient’s blood pressure varied from 120/80 to 100/70 torr. Arterial blood gas determinations were normal with the exception of a moderatelv severe metabolic acidosis. The mean fetal heart rate remained stable at 130 to 140 beats per minute throughout the procedure. Duration of anesthesia was 6 hours. The patient was returned to the recovery room in satisfactory condition, where fetal heart monitoring was rontinued. Fetal tachytardia has been demonstrated to be a sign of‘ maternal hypoxia in the third trimester of pregnanryi and fetal distress in the term infant.’ Similarly, loss of the normal variability of the fetal beat-to-beat interval has been recognized as an early sign of fetal distress2 In the first case there was a significant change in the fetal heart rate and rhythm, v+,hen only minimal changes were exhibited in maternal vital signs. These coincided with a period of inadvertent maternal hypoxemia (Fig. I, C) and are suggestive of fetal distress. The fetal heart rate rapidly returned toward baseline with improvement in maternal ventilation. After this
125 Number 2
correction, the fetal heart rate and maternal vital signs were stable for the remainder of the procedure (Fig. 1, D). In the second case there were no such blood gas irregularities and the fetal heart rate was stable throughout the surgical procedure. The potential value of the fetal heart rate monitor in demonstraung early changes in the fetal heart rate pattern during anesthesia and surgery is described. Fetal tachpcardia and a change to a more regular beat-to-beat interval is illustrated in one of the patients who had a transient period of hypoxemia. The patient in Case 1 required cesarean section (with peridural anesthesia) for cephalopelvic disproportion. A 3,160 gram male infant with Apgar scores of 8 and 10 at one and five minutes, respectively, was delivered. Both baby and mother were discharged in good condition. The patient in Case 2 was delivered of a 3,310 gram female infant with the aid of peridural anesthesia and low forceps. The baby’s Apgar scores were 8 and 8 at one and five minutes, respectively. Both baby and mother were discharged in good condition. REFERENCES
1. Cophen, D. E., and Huben, C. P.: Heart rate response of the human fetus to induced maternal hypoxia, AM. J. OBSTET.(;YNECOL.~% 320,1967. 2. Hon, E. H. G.: Direct monitoring of the fetal heart, Hosp. Pratt. 91: 5. 1970.
Variation of fetal presentation with gestational age KENNE.TH SCHEER, M.D., JEAN NUBAR, U.T.S.
Departmefzt of Obstettics and Gy~cology, Harvard Medical School, and The Boston Hospital for Women, Boston. Massachusetts THE RELATIVE frequency ofcephalic and breech (and other) presentations at various stages of pregnancy has long been of interest, chiefly because of the increased rate of neonatal morbidity and death with noncephalic delivery.] It is still controversial whether to attempt external version’ and it is questionable whether the outcome is actually altered by the procedure. It is only with the recent ability to investigate the amniotic cavity via ultrasound, that the fetal lie can be safely and accurately determined at virtually any stage of gestation. The advantages of this noninvasive radiation-sparing technique are well known. A review of all patients in the second half of pregnancy who were studied with ultrasound at the
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Scheer, 1180 Beacon St.,
Fig. 1. Relative frequencies of types of presentation. Table I. Progression increasing duration
of types of presentation of gestation
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
56 32 25 52 35 53 30 65 79 ;: 98 126 109 144 158 155 174 100 55 95
22 25 22 25 16 29 20 24 29 14 14 14 20 12 20 10 14 14 7 5 5
23 10 8 8 6 14 8 5 11 14 11 1 9 4 6 5 1 2 1 2 3
Boston Hospital for Women between January 1, 1974, and February 28, 1975, totalled 2,276 patients. The most common indications for sonography were: gestational age determination, size/dates discrepancy, second- and third-trimester bleeding, question of IUGR, and preamniocentesis placental localization. Only rarely was the scan performed to actually determine fetal lie. Fig. 1 and Table I demonstrate the relative frequencies of presentations and the progression with increasing duration of gestation.