Abdominal pregnancy near term, operation and hormonal studies of the blood and urine with the placenta left in situ

Abstract

T HE patient, who was thirty-four years of age and of Italian extraction, was admitted to the Norwegian Hospital on Nov. 18, 1935. Her physician had advised hospital care because of the severity of nausea, vomiting, constipation, and painfulness of fetal movements. Her past history aside from her menstrual, marital, and obstetric history was irrelevant. Her menses began at thirteen, occurred regularly at twenty-eight-day intervals and were of four-days duration, being associated with moderate dysmenorrhea. She had first married in 1919 and two pregnancies occurring shortly thereafter were terminated by induced abortions at three months and apparently were not followed by sepsis. After living with this husband for two years she divorced him and remarried in 1924. She did not conceive again until 1929 at which time a left salpingectomy was performed for a ruptured ectopic gestation. There were no pregnancies from then on until the one under consideration. The last menstrual period began on March 15, 1935 at the expected date and was normal in all respects. About four weeks later she began to spot and experienced cramplike pain such as she would have during her periods. This spotting and pain continued for the next two weeks, the bleeding on one occasion amounting to a definite flow for several hours. There was no further bleeding during the remainder of the pregnancy. Pain along the entire right side of the abdomen and chest was present at intervals associated with attacks of weakness. The pain was often relieved by enemas. Nausea and vomiting were a prominent symptom throughout, the patient losing eighteen pounds in weight. Constipation was a persistent symptom also. In the last trimester the fetal movements caused the patient great distress in the upper abdomen. I first saw her in consultation on November 27, three and one-half weeks prior to her estimated date of confinement. The patient was found to be a poorly nourished individual with a diminished hemic component, who did not appear well. Her temperature was 98.2” F., pulse 85, respirations 20, and blood pressure 116/76. Physical examination revealed no abnormalities aside from evidences of weight loss, the breast signs of pregnancy and the abdominal findings. The abdomen was greatly enlarged as though by a twin pregnancy. What first appeared to be the fundus uteri was found to be 27 cm. above the symphysis, and there seemed to be a marked widening of the upper portion of the abdomen. Palpation revealed, however, that the child was in the upper abdomen lying transversely with the head on the left side just beneath the co&al margin. The fetal parts were unduly prominent. The right lower quadrant of the abdomen was occupied by a semisolid fixed mass with a rounded upper edge which extended upward to slightly above the umbilicus and appeared to arise from the pelvis. This mass seemed to fuse with another mass which was also present in the lower abdomen to the left of the first mass extending over into but not completely filling the left lower quadrant and rising to the level of the umbilicus. The fetal heart was heard in the upper left quadrant. On vaginal examination the cervix was found high up