Volume 70 August 1977
533
Section of Obstetrics & Gyniecology President Sir Stanley Clayton FRCOG
Meeting 25 February 1977
Registrars' Papers Nine-week Survival of the Fetus following Spontaneous Mid-trimester Rupture of an Unscarred Uterus by F Ann Musson MRCOG (Willesborough Hospital, Ashford, Kent) A 21-year-old woman (a patient of Mr W Ursell), 27 weeks pregnant, was admitted to hospital on 8 May 1974 because of vaginal bleeding. She had had no operations. Two and a half years before she had had normal delivery of a live male child weighing 3.6 kg at 42 weeks gestation, which was followed by a transitory mild puerperal pyrexia and vaginal discharge. Six months later, during a urinary tract infection, she had a 10 week spontaneous abortion at home without excessive loss. This was not followed by curettage. From the start of the current pregnancy she had had recurrent small painless vaginal bleeds. On admission at 27 weeks gestation there was a history of sudden loss of two pints of blood per vaginam during micturition. There was no pain at the time, but slight low lumbar pain afterwards. There was no history of trauma. The pulse rate was 92 per minute, blood pressure 130/60 and temperature 37.8°C. She did not appear pale or feel faint, but was apprehensive. The fundal height was about 26 weeks gestation, the lie was longitudinal, and the presenting part appeared to be deeply engaged in the pelvis. The cervix was closed. A diagnosis of threatened abortion was made and she was treated with complete bed rest for one week, for five days of which she had, at times, a slight blood-stained watery loss per vaginam. There was no abdominal pain, but some abdominal tenderness. A pyrexia over 37.2°C developed on three occasions. From her admission onwards
the fetal movements changed in character, differing from the third trimester in her previous pregnancy. They were much stronger and 'more rolling than kicking'. Five days after the vaginal loss stopped she was gradually mobilized and discharged home. During the next eight weeks she complained repeatedly of abdominal pain which became more severe as pregnancy advanced. This was attributed to urinary tract infection and treated at home with antibiotics. At 35 weeks gestation she lost blood clots per vaginam followed by pinkish vaginal loss that. became yellow. The abdomen became extremely tender after this and she developed a pyrexia of 37.5°C. She was readmitted to hospital at 36 weeks gestation with a four-hour history of very severe pain in the lower abdomen, lumbar region and front and back of the lower thorax. She was restless with a pulse of 132 per minute and a blood pressure of 130/80. She had a 36-week-size fetus lying transversely and her abdomen was very tense and tender with generalized rebound tenderness despite intramuscular treatment with 15 mg morphia twenty minutes previously. The fetal heart sounds were loud and regular at 140 per minute. She was given an intravenous infusion of one litre 5 % dextrose, and a blood transfusion of group 0 Rhesus-negative blood was commenced. Laparotomy was performed through a lower midline incision. The fetus was found lying transversely in the peritoneal cavity which contained about two and a half litres of blood and clots. The umbilical cord passed through a rupture in. the fundus of the uterus to the placenta, which was still attached to the anterior and lateral endometrial surfaces of the uterine cavity except for a small part of the margin which was extruded through the rupture and was adherent to omentum. This adherence was so scanty that it could be divided without clamping vessels. The placenta was adherent to this endometrial surface except where it was raised in
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Proc. roy. Soc. Med. Volume 70 August 1977
little hillocks at irregular intervals about 3 cm apart. There were many adhesions between the bowel and the omentum in the epigastrium. At delivery the male infant had a strong, regular apex beat, but despite intubation and suction of blood-stained mucus from the trachea, and nalorphine injection, the baby died. The rupture in the uterus was bleeding in places, although other parts were healed. In spite of intravenous ergometrine it proved impossible to separate the placenta completely from the uterus, and bleeding also occurred from this incompletely cleared uterine surface. To control bleeding and deal with the partly healed rupture site, a total abdominal hysterectomy was carried out. The patient was transfused with 4 units of blood. Postoperatively she was given prophylactic tetracycline (patient allergic to penicillin). She developed wheezing, pyrexia and transitory blood-stained sputum, with no clinical deep vein thrombosis and a normal chest X-ray. She was given dextran infusion and made a satisfactory recovery. Histology of the uterus (Dr V H Bowers) showed the edge of the rupture to have been healing for several weeks. At post-mortem examination (Dr V H Bowers), the infant was found to be normally formed and well nourished as indicated by the weight of 2.9 kg at 50 cm length. The finger and toenails extended beyond the end of the respective digits. Four ossification centres were found in the sternum, but none at the lower end of the right femoral epiphysis. There were multiple petechial hemorrhages over the surfaces of lungs and heart, and the blood was dark purple. The lungs were dark purple in colour; they and the liver, kidneys and meninges were acutely congested. No cause was found for the asphyxia neonatorum indicated by these findings. Discussion No case of rupture of an unscarred uterus, with the fetus subsequently living for months before delivery, has been found in the literature of the last twelve years. The only two similar cases described are of rupture of a scar in the uterus. The first of these cases (Pauwen 1964) concerned a patient who conceived immediately after reimplantation of a fallopian tube, performed to reverse a sterilization operation. In this case symptoms suggested rupture at 12 weeks, and at laparotomy at term the fetus was found lying within a translucent sac of membranes. The cord passed through a rupture in the uterus about 3 cm diameter at the site of reimplantation. The second case was reported by Hubenthal in 1966. The patient had had a myomectomy eighteen years before, and a cornual pregnancy treated by wedge excision of the cornu twenty-two years before. In this case rupture of the uterus appears to have occurred at 16 weeks.
Laparotomy at term revealed the fetus in t peritoneal cavity lying in an amniotic sac with t cord passing through the site of the wedge excisi of the cornu. In both these cases it proved i: possible to separate the placenta from the uter and hysterectomy was performed. In reviewing the possible predisposing factors rupture in our patient we considered whet} possible puerperal infection in her first pregnan( or retained products of conception after her spc taneous abortion, might have predisposed to a normal infiltration of the uterus by trophobla However, sections cut from the edge of the uteri rupture did not show abnormal infiltration trophoblast. Another possibility was of und covered interference. A procured abortion seem very unlikely indeed, as the patient desperat( wanted a further pregnancy. Thus there was satisfactory explanation for the rupture of t uterus in this case. REFERENCES Hubenthal A (1966) Zentralblatt fur Gynakologie 88, 462 Pauwen J (1964) Zentralblattfiir Gynakologie 86, 1514
Cosmetic Vulval Surgery following Repair of Ectopia Vesicae by R J Rhodes chB MB (Hope Hospital, Eccles Old Road, Salford M6 8HD)
Ectopia vesicx (or bladder exstrophy as it is mc logically termed in the United States) occurs as rare congenital anomaly variously estimated in t female at 1 in every 60 000 to 150 000 live femr births. The anomaly occurs in the embryo at abc the third week or slightly later, with extroversi, immediately inferior to the umbilical cord. It postulated that over enlargement of the cloac membrane prevents normal fusion of the genii tubercles and hence normal bony and muscul fusion of the pelvis and lower abdomen. The posterior wall of the bladder is continuo with the lower anterior abdominal wall and t ureters thereby open directly onto the body si face. The resulting susceptibility to ascending u nary tract infection in untreated cases is so gre that only 23 children out of a series of 74 reach the age of 20 years (Buerger 1916). The urethra absent, the labia minora are rudimentary ai usually the clitoris, is bifid. The labia majora a represented by patches of hair-bearing skin in ea
533
Section of Obstetrics & Gyniecology President Sir Stanley Clayton FRCOG
Meeting 25 February 1977
Registrars' Papers Nine-week Survival of the Fetus following Spontaneous Mid-trimester Rupture of an Unscarred Uterus by F Ann Musson MRCOG (Willesborough Hospital, Ashford, Kent) A 21-year-old woman (a patient of Mr W Ursell), 27 weeks pregnant, was admitted to hospital on 8 May 1974 because of vaginal bleeding. She had had no operations. Two and a half years before she had had normal delivery of a live male child weighing 3.6 kg at 42 weeks gestation, which was followed by a transitory mild puerperal pyrexia and vaginal discharge. Six months later, during a urinary tract infection, she had a 10 week spontaneous abortion at home without excessive loss. This was not followed by curettage. From the start of the current pregnancy she had had recurrent small painless vaginal bleeds. On admission at 27 weeks gestation there was a history of sudden loss of two pints of blood per vaginam during micturition. There was no pain at the time, but slight low lumbar pain afterwards. There was no history of trauma. The pulse rate was 92 per minute, blood pressure 130/60 and temperature 37.8°C. She did not appear pale or feel faint, but was apprehensive. The fundal height was about 26 weeks gestation, the lie was longitudinal, and the presenting part appeared to be deeply engaged in the pelvis. The cervix was closed. A diagnosis of threatened abortion was made and she was treated with complete bed rest for one week, for five days of which she had, at times, a slight blood-stained watery loss per vaginam. There was no abdominal pain, but some abdominal tenderness. A pyrexia over 37.2°C developed on three occasions. From her admission onwards
the fetal movements changed in character, differing from the third trimester in her previous pregnancy. They were much stronger and 'more rolling than kicking'. Five days after the vaginal loss stopped she was gradually mobilized and discharged home. During the next eight weeks she complained repeatedly of abdominal pain which became more severe as pregnancy advanced. This was attributed to urinary tract infection and treated at home with antibiotics. At 35 weeks gestation she lost blood clots per vaginam followed by pinkish vaginal loss that. became yellow. The abdomen became extremely tender after this and she developed a pyrexia of 37.5°C. She was readmitted to hospital at 36 weeks gestation with a four-hour history of very severe pain in the lower abdomen, lumbar region and front and back of the lower thorax. She was restless with a pulse of 132 per minute and a blood pressure of 130/80. She had a 36-week-size fetus lying transversely and her abdomen was very tense and tender with generalized rebound tenderness despite intramuscular treatment with 15 mg morphia twenty minutes previously. The fetal heart sounds were loud and regular at 140 per minute. She was given an intravenous infusion of one litre 5 % dextrose, and a blood transfusion of group 0 Rhesus-negative blood was commenced. Laparotomy was performed through a lower midline incision. The fetus was found lying transversely in the peritoneal cavity which contained about two and a half litres of blood and clots. The umbilical cord passed through a rupture in. the fundus of the uterus to the placenta, which was still attached to the anterior and lateral endometrial surfaces of the uterine cavity except for a small part of the margin which was extruded through the rupture and was adherent to omentum. This adherence was so scanty that it could be divided without clamping vessels. The placenta was adherent to this endometrial surface except where it was raised in
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Proc. roy. Soc. Med. Volume 70 August 1977
little hillocks at irregular intervals about 3 cm apart. There were many adhesions between the bowel and the omentum in the epigastrium. At delivery the male infant had a strong, regular apex beat, but despite intubation and suction of blood-stained mucus from the trachea, and nalorphine injection, the baby died. The rupture in the uterus was bleeding in places, although other parts were healed. In spite of intravenous ergometrine it proved impossible to separate the placenta completely from the uterus, and bleeding also occurred from this incompletely cleared uterine surface. To control bleeding and deal with the partly healed rupture site, a total abdominal hysterectomy was carried out. The patient was transfused with 4 units of blood. Postoperatively she was given prophylactic tetracycline (patient allergic to penicillin). She developed wheezing, pyrexia and transitory blood-stained sputum, with no clinical deep vein thrombosis and a normal chest X-ray. She was given dextran infusion and made a satisfactory recovery. Histology of the uterus (Dr V H Bowers) showed the edge of the rupture to have been healing for several weeks. At post-mortem examination (Dr V H Bowers), the infant was found to be normally formed and well nourished as indicated by the weight of 2.9 kg at 50 cm length. The finger and toenails extended beyond the end of the respective digits. Four ossification centres were found in the sternum, but none at the lower end of the right femoral epiphysis. There were multiple petechial hemorrhages over the surfaces of lungs and heart, and the blood was dark purple. The lungs were dark purple in colour; they and the liver, kidneys and meninges were acutely congested. No cause was found for the asphyxia neonatorum indicated by these findings. Discussion No case of rupture of an unscarred uterus, with the fetus subsequently living for months before delivery, has been found in the literature of the last twelve years. The only two similar cases described are of rupture of a scar in the uterus. The first of these cases (Pauwen 1964) concerned a patient who conceived immediately after reimplantation of a fallopian tube, performed to reverse a sterilization operation. In this case symptoms suggested rupture at 12 weeks, and at laparotomy at term the fetus was found lying within a translucent sac of membranes. The cord passed through a rupture in the uterus about 3 cm diameter at the site of reimplantation. The second case was reported by Hubenthal in 1966. The patient had had a myomectomy eighteen years before, and a cornual pregnancy treated by wedge excision of the cornu twenty-two years before. In this case rupture of the uterus appears to have occurred at 16 weeks.
Laparotomy at term revealed the fetus in t peritoneal cavity lying in an amniotic sac with t cord passing through the site of the wedge excisi of the cornu. In both these cases it proved i: possible to separate the placenta from the uter and hysterectomy was performed. In reviewing the possible predisposing factors rupture in our patient we considered whet} possible puerperal infection in her first pregnan( or retained products of conception after her spc taneous abortion, might have predisposed to a normal infiltration of the uterus by trophobla However, sections cut from the edge of the uteri rupture did not show abnormal infiltration trophoblast. Another possibility was of und covered interference. A procured abortion seem very unlikely indeed, as the patient desperat( wanted a further pregnancy. Thus there was satisfactory explanation for the rupture of t uterus in this case. REFERENCES Hubenthal A (1966) Zentralblatt fur Gynakologie 88, 462 Pauwen J (1964) Zentralblattfiir Gynakologie 86, 1514
Cosmetic Vulval Surgery following Repair of Ectopia Vesicae by R J Rhodes chB MB (Hope Hospital, Eccles Old Road, Salford M6 8HD)
Ectopia vesicx (or bladder exstrophy as it is mc logically termed in the United States) occurs as rare congenital anomaly variously estimated in t female at 1 in every 60 000 to 150 000 live femr births. The anomaly occurs in the embryo at abc the third week or slightly later, with extroversi, immediately inferior to the umbilical cord. It postulated that over enlargement of the cloac membrane prevents normal fusion of the genii tubercles and hence normal bony and muscul fusion of the pelvis and lower abdomen. The posterior wall of the bladder is continuo with the lower anterior abdominal wall and t ureters thereby open directly onto the body si face. The resulting susceptibility to ascending u nary tract infection in untreated cases is so gre that only 23 children out of a series of 74 reach the age of 20 years (Buerger 1916). The urethra absent, the labia minora are rudimentary ai usually the clitoris, is bifid. The labia majora a represented by patches of hair-bearing skin in ea
