Extra-U terine Hemorrhage in Parturition. BY C. C. THAYER, M. D., CLIFTON SPRINGS, N. Y. REPRINTED FROM THE Nete STorfe JtacUfcal journal for April 4, 1896. Reprinted from the New YorJc Medical Journal for April f 1896. EXTRA-UTERINE HAEMORRHAGE IN PARTURITION. By 0. 0. THAYER, M. D., CLIFTON SPRINGS, N. Y. This is one of the most anxious complications of labor. Fortunately it seldorr) occurs. Many an obstetrician of ex- tensive hospital and general practice has never met with a case, and medical literature on this subject is correspond- ingly meagre. In the year 1830, Deneux, of Paris, wrote an able article on Blood Tumois of the Vulva and Vagina, which called forth during the following thirty years many other articles on haematocele, haematoma, haemophilia, varix, and other subjects relating to pathological haemorrhages in the puerperal state, by M. Nelaton, M. Huguier, M. Reca- mier, and M. Bernutz, in the Archives de medecine, June, 1848, and 1857 ; the Bulletin, June 4, 1851 ; and M. Ber- nutz’s Diseases of Women, vol. i. Much later, Dr. Tilt, Dr. Ilewitt, and Dr. Simpson wrote on kindred subjects ; also Matthews Duncan, in the Edinburgh Medical Journal, No- vember, 1862 ; but none of these describe exactly the kind of case intended by this article. Dr. Tuckwell, of Oxford, writing on Effusions of Blood in the Neighborhood of the Uterus, 1863, ably describes COPYRIGHT, 18%, BY l>. APPLETON AND COMPANY. 2 EXTRA-UTERINE HAEMORRHAGE IN PARTURITION. the condition in general, but as resulting from various causes other than the conditions and processes of parturition. I desire to call attention in this article to extra-uterine haemorrhage induced by the conditions and processes of parturition—parturition mature, or parturition premature— abortion, miscarriage, or full-term labor. The causes of intra-uterine and extra-uterine haemor- rhage in parturition are similar, except in location and ex- pression, the one being within and the other without the uterine organ. Tumors, haematocele (effusion of blood into the pelvic peritoneal cavity), haematoma (effusion of blood into the pelvic subperitoneal cavity), haemophilia (ab- normal tendency to haemorrhage), varix (venous dilatation), and tissue necrosis are among the infrequent causes; but that tubal “ menstrual flux,” or rupture of the Graafian fol licles or parovarian sacs, could produce haemorrhage in labor, or from labor, taxes credulity. The pre eminent causes are ectopic or extra-uterine gestation and maternal and instrumental efforts in delivery, from ruptured tissue or burst blood-vessels, usually accidental and non-pathologi cal. Tubal abortion and tubal rupture are fruitful causes of this form of haemorrhage. If from tubal abortion, the haemorrhage must necessarily be within the first weeks of pregnancy, for while the tube is being gradually dilated about the impregnated ovum, the fimbriated end is being correspondingly contracted by the general congestive, hy- pertrophic, and hardening influence of the process of ges tation on the unsupported termini of the tube, inclosing the fimbriae and occluding the tube during the first two months of gestation. The haemorrhage in this case is into the peritoneal cavity. If from tubal rupture, the haemorrhage occurs at the time of rupture, which may be at any time during the puerperal state ; and if tubo-ovarian (above the peritoneal covering), the effusion is into the peritoneal EXTRA-UTERINE HAEMORRHAGE IN PARTURITION. 3 cavity ; but if the rupture is in the bottom of the tube, the haemorrhage is into the folds of the broad ligament, and in either case it must result in absorption, inflamma- tion, or encasement, with new environments in some of the more pendent portions of the body—viz., the utero-vesi- cal, the prae-vesical, or Douglas’s pouch. While ectopic gestation is to be regarded as the most frequent cause of extra-uterine haemorrhage in parturition, we must not pass unnoticed the rarest and gravest accident in labor—rupture of the uterine walls—which usually proves fatal to both mother and child. There may be haemor- rhage from a pre existing adhesion, from infiltration, sub- mucous or interstitial, into the walls of the vagina and vul- va, from varicose veins, from foetal or instrumental injury, from depraved tissue and abscess. Diagnosis.—The symptoms indicating concealed haem- orrhage are sudden pain, shock, thirst, pallor, sighing, gasp- ing, chills, sweat, restlessness, tossing of the arms, begging for help, dilated pupils, dimness of vision, rapid, tense, and contracted pulse, and subnormal temperature. The local and subjective symptoms of extravasations of blood into the substance of organs, areolar tissue, or internal cavities are swelling, dullness on percussion, displacement of organs or parts, succession, and discoloration. Treatment.—In extra-uterine haemorrhage from tubal abortion or rupture, however much one might crave sur- gical interference for extricating the displaced foetus, for reducing the tubal rupture, and for removing the ex- travasated blood, yet, as a thing is important according to its utility, surgery is not at first most important, because it can not be utilized. The condition that presses for atten- tion above all others and demands immediate help is the systemic shock. The shock necessarily defers operation. Ergot and aromatic sulphuric acid in full doses should be 4 EXTRA-UTERLXE HAEMORRHAGE IN PARTURITION. given and continued; and trillium erectum, one drachm of the tincture in hot water every half hour, in connection with ergot or alone, should be administered ; while sub- cutaneous injections of ether, brandy, or whisky, at a tem- perature of 110°, with copious draughts of hot water with a little table salt in it to sustain the volume of arterial fluid, hot milk diluted with hot water, beef tea, or hot gruel, with external heat to prevent collapse, should be pushed with energy, remembering that the chill of the shock is in itself devitalizing. Nothing steadies and sustains the nervous system in shock better than subcutaneous injections of morphine, and a quarter of a grain should be given as soon as possible. Darkness, fresh air, and quiet are favorable conditions. The first ray of hope in the case is recovery from the shock, the second from absorption of the extravasated blood, and the third from foetal extirpation or capsulation. After recovery from the shock the treatment will be indicated by the determination of the effusi m and products of conception. Surgery here may prove most useful. Should the effusion be intraperitoneal, the most probable determination is into the pouch of Douglas, whence it can be withdrawn by care ful aspiration—a comparatively safe operation with the use of an aseptic aspirating needle fitted to a self-delivering hypodermic syringe, thus preventing the introduction of air into the peritoneal cavity. The products of conception in this case must be dealt with, if at all, by surgical inter- ference. Should the effusion and products of conception lodge in the broad ligament, coeliotomy is indicated, but without operation a fatal termination is by no means certain. Many spontaneous recoveries from this accident have been recorded, as well as many patients who in after years, as Dr. Watts says in his hymn, “ Live at a poor dying rate,” the EXTRA-UTERINE HAEMORRHAGE IN PARTURITION. 5 cause of their impaired health pointing to this anomaly. Dr. Mann recites a case of fifteen years’ standing where the foetal remains were lemoved from the pouch of Douglas, and this was followed by recovery. Other authors speak of foetal remains abiding capsulated for twenty, thirty, and forty years. For preventing or overcoming inflammatory action, sitz baths of a temperature of from 70° to 80° F., for from ten to eight minutes, combined with the foot ba'h, of a tern perature of 110°, or an ice bag over the affected region, with antiphlogistic remedies, are indicated. Should haemorrhage in parturition occur from rupture of a haematocele, hasty delivery and sustaining the patient are all that is required at the time “ The mere presence of a large amount of blood in the peritonaeum,” says Thomas (Diseases of Women, p. 498), “does not warrant evacua- tion. If, as time passes, suppuration . . . and septic ab- sorption are manifested, . . . the mass should be dis- charged by incision.” Should there be rupture of the uterine walls, says Play- fair (Midwifery, p. 392), and “ the foetus be entirely with- in the uterine cavity, the proper course to pursue is to deliver at once per vias naturales, either by turning, by for- ceps, or by cephalotripsy.” If the child has escaped into the abdominal cavity, gastrotomy offers the best results, as is shown in Jolly’s tabulated statistics of 564 cases: Treatment. No. of cases. Deaths. Recoveries. 144 142 2 382 310 72 Gastrotomv 38 12 26 Tn natural labor the extra uterine extravasation will drift along the course of the rectum and vagina, and, if ex- tensive, will obstruct the foetal progress, the ultimatum of 6 EXTRA-UTERINE HAEMORRHAGE IN PARTURITlOxN. which will be rupture of the vagina, vulva, or perinseum before delivery. As aspiration is better than rupture, it should be employed, and as far away from the genitalia as possible, to avoid subsequent sepsis. A case in hand will illustrate : I was called to attend a lady, aged twenty-seven years, healthy, and a primipara. It was 1.30 a. m. Her pains at that time were only cervical. With an aseptic finger I found the dilating os of about the size of a half dollar. At 2 a. m. I found rapid progress. At 3 a. m. the amniotic fluid was dis- charged. At 3.30 a. m. I found a vertex presentation, with a left oocipito-sacro-iliac engagement, muscular contractions strong and rapid, pulse firm, “ and every prospect brightened.” At 4 a. m. she suddenly and unexpectedly began to look pale, her pulse was rapid and nervous, a cold sweat broke out, and a sudden anxiety seized both patient and doctor—now both in travail. On vaginal examination, I found on the left and outside of the vagina, in the cellular tissue and on a level with the cervix, a mushy mass which I diagnosticated at once as blood, and the foetal occiput was impinging on it. At 4.30 the mass and head seemed of about the same size, and so vigorous and rapid were the uterine contractions and so firm was the resisting mass, that the previous vertex bad become a face presentation, or so much so that the face and chin could be clearly outlined. Satisfied that the child could never be born till the mass was removed, I resolved to aspirate it; and while I was directing the servant to bring my instru- ments a strong uterine muscular contraction ruptured the vaginal wall from the lower third through to the left ischio- rectal fossa, discharging the most blood from the triangular space between the ischio-cavernosus and the transversus perinjei muscles, a wound three inches and a half long, and deep, with another rupture from this diverging outward to- ward the extended leg an inch and a half, making a large and ugly wound, out of which the fresh blood gushed with great force at first and flowed freely until the expulsion of the foetus. On my pressing the foetal face up at once, the EXTRA-UTERINE HEMORRHAGE IN PARTURITION. 7 occiput, now Laving ample room, rotated favorably during the next contraction, and the following contraction expelled the child, and the haemorrhage ceased. The collapsed state of the patient was now distressing. The pulse was hardly countable, the temperature was 96°, and the respiration was 11, with besom de respirer, sighing, begging for help, bidding friends farewell, and sinking into a semi-unconscious state, covered with cold perspiration. A carbolized absorbent cotton pad was placed over the wound, the head was lowered, windows were opened, hot bottles were placed about the patient, hot milk diluted was freely and fre- quently administered with stimulants, and a subcutaneous in- jection of morphine, a quarter of a grain, with atropine, was given. Superficial rubbing and stimulation were vigorously pushed, and the patient was carefully watched by my col- league, Dr. Spaulding, and myself for five hours uninterrupt- edly before we felt it safe to leave her. We again sponged her body with a solution of bichloride of mercury, packed the vagina with carbolized absorbent cotton (1 to 60) to prevent infecting the wounds, irrigated them with carbolized hot wa- ter, and packed them with iodoform gauze—for they were deep—having previously shortened them with three deep su- tures. Three times daily we used the vaginal douche with a carbolic solution, and repacked tightly with carbolized cot- ton, after which we irrigated the wounds and repacked them, being careful always not to unpack the wounds till after cleansing and repacking the vagina. The patient continued to improve, and after the “ milk fever ” we freshened the edges of the remaining wound and put in four more deep sutures—seven in all—and secured perfect union with com- plete recovery. The source of this quantity of fresh blood was not discovered. 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