[Reprinted from the Transactions of the Association of Obstetricians and 
Gynecologists, June, 1893.] 
PREGNANCY FOLLOWING A PARTIAL SUPRA- 
PUBIC HYSTERECTOMY, COMPLICATED 
BY HEMORRHAGE THROUGH THE 
ABDOMINAL CICATRIX. 
By X. O. WERDER, M.D., 
PITTSBUgg.^ 
The case which I am about to describe is so interesting and, I 
believe, unique in many of its features that I choose this opportunity 
to put it on record. 
Mrs. Mary L., twenty-nine years old, married since August, 
1890, but sterile, consulted me for the first time in June, 1891. 
She had been in good health until about five or six months ago, 
when she noticed a slight enlargement of her abdomen, accom- 
panied by discomfort and, at times, pains in her pelvis. The swell- 
ing of her abdomen gradually increased until at the time she first saw 
me it had attained the size of a five or six months' pregnancy; with 
the enlargement of her abdomen the discomfort in the pelvis in- 
creased. The pains "at the bottom of the bowels" became very 
severe and were of a bearing-down character. Locomotion was very 
much interfered with and she was frequently unable to lie down a 
night. Her digestion became deranged and her health began to 
fail. While she possessed a fair amount of adipose, she was pale 
and anemic and the least exertion fatigued her. Her menses, which 
for years had been somewhat painful, were now accompanied by 
cousiderable suffering, though the flow was scanty, lasting only 
three days. An examination showed a firm, hard, and roundish 
tumor, occupying the centre of the abdomen and extending from 
the symphysis pubis to the umbilicus and attached to the pos- 
terior surface of the fundus uteri. Tonic treatment continued for 
three months produced a marked improvement of her general health, 
but had no effect on the local condition in the pelvis. She was 2 
X. O. WERDER, 
advised to go to Mercy Hospital, where for two months electricity 
was applied according to Apostoli's method, a total of fifteen appli- 
cations in all, varying from 100 to 150 milliamperes. This treat- 
ment neither affected the size of the tumor nor did it produce the 
slightest symptomatic improvement, so that the patient clamored for 
operation, which was performed December 3, 1891. 
The tumor was a fibromyoma attached by a very broad and 
thick pedicle to the posterior and right surface of the fundus uteri. 
The base of the tumor was encircled by the elastic ligature closely 
hugging the uterus, and as subsequent events proved, including a 
small portion of the uterus itself. The tumor was transfixed with 
pedicle needles immediately above the elastic ligature and cut oil 
above this point. The uterine cavity had not been opened. The 
pedicle was fixed in the lower angle of the wound in the usual way. 
The tumor weighed twelve pounds. Convalescence was uninter- 
rupted. Ligature and pedicle came away on the twentieth day. 
Patient left the hospital January 17, 1892, about six weeks after 
the operation, with a small fistulous opening at the bottom of the 
abdominal wound. Her menstrual period returned February 19, 
about a month after leaving the hospital, and at this time she 
noticed a slight bloody discharge from this sinus. 
In March her catamenia did not appear at the expected time, and 
soon afterward other symptoms of pregnancy developed. About 
this time I found the cervix high up in the pelvis, uterus firmly 
attached to the abdominal wall, soft, elastic, and enlarged. The 
fistula in the lower angle of the wound was still open--just about 
large enough to introduce a sound. A subsequent examination 
(about a month later) confirmed the diagnosis of pregnancy. She 
was then having some pain in the pelvis, about the uterine attach- 
ment to the abdominal walls. With the exception of this pain, or 
rather discomfort, her pregnancy progressed very favorably thus 
far. At the beginning of the fourth month a gradual rotation of 
the uterus began at its point of fixation to the abdominal wall, i.e., 
the uterine tumor no longer occupied the middle of the abdomen, 
but began to crowd more to the left of the median line. During 
her whole pregnancy, the left side of abdomen was the principal 
seat of the pregnant uterus, it scarcely reaching beyond the median 
line toward the right side. 
At the end of the fourth month there was a copious hemorrhage PREGNANCY FOLLOWING PARTIAL HYSTERECTOMY. 
3 
from the fistulous opening at the lower angle of the abdominal cica- 
trix, which by this time had become enlarged from the internal 
pressure to the size of a half-dollar, the amount of blood lost being 
at least a pint, according to the estimate of the patient. About 
three weeks later there was another hemorrhage from the same 
place, to the amount of a teacupful of blood. At the end of the 
sixth month she again lost about a cupful of blood. There were 
seven hemorrhages in all, five of which were profuse, producing a 
marked anemia of the patient and causing a great deal of anxiety 
as to the ultimate result. In order to have her under better con- 
trol, and to be ready for any emergency that might arise, I advised 
her to go to the Rosalia Maternity Hospital, which she entered 
October 26, 1892. The last hemorrhage had occurred about a week 
before her admission to the hospital. During the last six or eight 
weeks she had remained in bed, hoping that by absolute rest the 
hemorrhages would be less likely to return. 
Labor began October 30th, four days after entering the hospital, 
but at least three weeks before her expected confinement. The os 
uteri at the time of labor was very high up and very hard to reach. 
First stage of labor was very slow ; dilatation not complete until 
early the next day. The patient by that time being pretty well 
exhausted, it was terminated by forceps. During labor there was 
only a slight bloody oozing from the fistulous opening. The child 
was living, but very small and thin. The placenta was found ad- 
herent just under the fistulous opening from which the bleeding 
had taken place, requiring manual separation. At this place, the 
hand in the uterus noted an apparent absence of the uterine wall, 
and the placenta seemed to be attached to the abdominal wall, 
around the external sinus. The abdominal wall was extremely 
thin, as could be easily ascertained by the hand placed over it and 
pressing against that in the uterus. After emptying the uterus it 
contracted at once, leaving a small depression in the abdominal 
wall around the fistula. The loss of blood during the third stage 
of labor was not considerable. Patient made an uninterrupted re- 
covery and left the hospital on November 28th, with a living, healthy 
child, just four weeks after her delivery. The fistulous opening 
had become perfectly closed by that time. 
Mrs. L. presented herself to me for examination May 2, 1893, 
with her child, which was hearty and well. The patient has been 4 
X. O. WERDER, 
in good health since she left the Maternity Hospital. She has not 
menstruated since, and she is still nursing her child. Abdom- 
inal wound perfectly healed; no trace of fistulous opening. The 
cervix is very high up in the pelvis ; uterus small, measuring two 
and one- half inches, still firmly attached to the abdominal wall. The 
body of the uterus seems to consist of two distinct cavities, the one 
on the left evidently being the uterine cavity proper; turning the 
sound a little to the right, it enters another cavity which is about one- 
fourth of an inch deeper than the other and leads to the bottom of the 
abdominal cicatrix, the former fistulous opening, at which place the 
point of the sound can be distinctly felt directly under the cicatrix. 
There is no doubt in my mind that the slough under the elastic 
ligature extended into the body of the uterus and on separating 
opened the uterine cavity, and that there was a direct communica- 
tion between the fistulous opening in the abdominal wound and the 
uterine cavity, which allowed some of the menstrual blood to escape 
through it at her menstrual period ; and that, furthermore, the source 
of the hemorrhages during pregnancy was the placenta itself, the upper 
edge of which was attached immediately under the bleeding surface. 
Menstruation through an abdominal fistulous opening occurred 
in another case in which I removed a fibroid tumor of the uterus 
with thick, short pedicle in a young woman, the case being almost 
identical with the oue described above. The pedicle was treated 
in the same manner as in the previous one. During the first and 
second day of every menstrual period, which lasts from three to 
four days in all, there is a slight bloody discharge through an open- 
ing in the lower angle of the abdominal cicatrix not larger than the 
head of a pin, which during the inter-menstrual period is marked 
by a minute black spot. 
Pregnancy following a complete hysterectomy, of course, would 
be an impossibility, but even following the more conservative oper- 
ations upon the uterus for subperitoneal or pedunculated fibroids, it 
seems to be a very rare occurrence. lu A. Martin's seventy-eight 
recoveries following enucleation of fibroid tumors,1 in which the 
cavity of the uterus remained intact, pregnancy occurred only once; 
in addition to this he was able to record only two more cases iu 
which gestation followed the same operation. In the literature at 
1 "Ueber Myomoperationen," in Zeitschrift fiir Geburtshtilfe und Gynakologie, 1890. PREGNANCY FOLLOWING PARTIAL HYSTERECTOMY. 
5 
my disposal I was not able to find a single case followed by preg- 
nancy in which a part of the uterus was removed, as was evidently 
done in the case reported. 
The fact that pregnancy does occur, however, though in a very 
small percentage of eases, should induce us, in the first place, to 
practise conservatism in the performance of these operations, i. e., 
where we have to deal with a single tumor in the uterus of a young 
woman which can be removed without sacrificing the whole corpus 
uteri, we should try, in ray opinion, to preserve that organ in as 
nearly a normal condition as possible. This object can, in cases 
such as the subject of this paper, be best attained, in my opinion, 
by the enucleation of the tumor as practised by A. Martin. While 
enucleation does not increase the risks of the operation very materi- 
ally, it has this decided advantage over the method employed in 
my case, that it leaves an absolutely intact uterine cavity without 
fixation of the uterus to the abdominal wall, and would, therefore, 
pervent any unpleasant and dangerous complications, such as en- 
countered in the case reported. 
To summarize briefly, the principal points of the case described 
are: 
1. The menstrual discharge through a small fistulous opening, 
remaining after a partial supra-vaginal hysterectomy, which com- 
municated with the cavity of the uterus. 
2. Pregnancy occurring eight or nine weeks after operation in a 
woman previously sterile in spite of a utero-abdominal fistula. 
3. Pregnancy terminating in the delivery of a healthy though 
poorly developed child at, or at least near, the end of her term, in 
spite of a firm and unyielding fixation of the uterus to the abdom- 
inal wall, and in spite of frequent and profuse hemorrhages from 
the placental site, through a sinus opening in the lower angle of 
the abdominal cicatrix.