5 September 1953 S.A.
TYDSKRIF VIR GENEESKUNDE
TABLE m: SUMMARY OF SERUM PROTEIN-BOUND IODINE RESULTS
IN 46 PATIENTS
Final Clinical Serum PB] p.g. % B.M.R. de terminations, considering that these estimations
Assessmenr of Number of
Thyroid State Cases Range Mean
Hypothyroid 5 0·6-2·2 1·3
Euthyroid 23 2-0--7'7 4·7
Hyperthyroid 18 6,7-24,0 11·3
PLACENTA SUCCENTURIATA AS A CAUSE OF ANTE-PARTUM HAEMORRHAGE
W. FRASER Ross, B.Sc., M.B., CH.B. (ST. AND.)
(From the Government Medical Service, Southern Rhodesia)
As ante-partum haemorrhage due to placenta succenturiata
appears to be uncommonly recorded in the literature, a
case is described which presented as an ante-partum
haemorrhage of some severity.
CASE REPORT
A Bantu woman, about 18 years of age, was admitted to
the Maternity Unit, Harari African Hospital, Salisbury, at
11 a.m. on 16 November, 1950. She gave a history of
intermittent vaginal bleeding since 11 November with
vague abdominal pains; she had misse1 nine menstrual
periods but did not know the date of her last menstrual
period. She was a primipara, had felt well up to the
commencement of bleeding, and had not had any medical
attention until admission. The woman stated that she
had not felt any foetal movements since the day after
the haemorrhage had begun but she was vague as to how
much blood she had lost.
Examination on admission showed a young Bantu
woman, extremely shocked, with very pale mucous mem-
branes, pu'se of poor volume, rate 140 per minute, blood
pressure 70/30, temperature 97.6° F with rapid respira-
tions. Abdominal palpation revealed a 40 weeks'
pregnancy, breech right sacro-anterior, with no foetal
heart heard. There was nothing abnormal in the chest
except a generalized systolic murmur heard over the
cardiac area. From the history and examination a
diagnosis of placenta praevia was made and treatment
for shock and haemorrhage was instituted.
Blood-grouping showed her blood to be Group A and
a haemoglobin estimation made at this time by a Sahli
haemoglobinometer was 25 ~~. She was given morphine
sulphate gr. t (IS mg.) and dextran solution was given
intravenously until compatible blood could be obtained.
One pint of dextran, 2 pints of Group 0 and 1 pint of
Group A compatible blood were given, the first rapidly
and the others more slowly. During this time the patient
drank freely and slept, and her condition steadily
improved; there was no further haemorrhage vaginally,
the pulse rate fell to 90 per minute and the blood pressure
rose to 100/60 by 8 a.m. on 17 November.
On that day at 8.15 a.m. a vaginal examination was
773
results indicate a reasonable correlation of serum PBI
levels with the final clinical diagnosis. Figure 3 also shows
a reasonable relationship of serum PBI levels with the
are fundamentally quite different. In Table III a summary
is presented of the findings in 46 of the patients shown in
Table -n. The results in 14 patients where the clinical
diagnosis was in doubt, and in whom the final clinical
assessment of the thyroid state is queried in Table n, have
been omitted.
(To be concluded)
made and a 2-finger os was felt with placental tissue cover-
ing the whole of the os. On finding this no further
examination was attempted. As no foe:al heart could be
heard it was decided to give a further pint of compatible
blood and leave the patient until her improved condition
had stabilized (she had been lying in a grass hut for 5
days previous to her admission). During the giving of this
further pint of Group A blood, a brisk vaginal haemo-_
rrhage set in and a Caesarean section was decided on.
A classical Caesarean section was carried out at
10.20 a.m. under general anaethesia. When the uterus
was opened the incision on the anterior wall revealed the
placenta lying underneath. This was pushed aside and a
macerated male foetus, weight 7 lb. 3 oz., was delivered.
The placenta was next removed but the membranes could
not be easily delivered. It was then seen that a small
lobe of placental tissue was on the lower segment entirely
covering the internal os. This was removed by blunt dis-
section as it was rather adherent at one point, which
resulted in considerab!e haemorrhage. The uterus was then
sutured in layers and the abdomen closed. During the
operation a further pint of dextran and a pint of Group A
blood was given. At the end of the operation the patient's
condition was reasonable.
The patient was given soluble penicillin in 100,000 unit
doses 6 hourly for 2 days, followed by 1 c.c. procaine
penicillin (Glaxo) twice daily fO!: 3 days. Her post-
operative convalescence was uneventful apart from a
slight bronchitis from 20 to 22 November. She was dis-
charged from hospital on 4 December, general condition
good, haemoglobin (Sahli) 90%, abdominal wound well
healed. Seen post-natally on 17 January 1951 she said
she felt well and nothing abnormal could be found.
COMMENT
The history and clinical examination of this patient in
every way pointed to a diagnosis of placenta praevia. The
unusual severity of the haemorrhage suggested a placenta
praevia of Type III or IV and the recurrence of the bleed-
ing after the transfusion of the blood prompted the carry-
ing out of a Caesarean section, when the placenta was
revealed as being on the anterior uterine wall. Because of
774 S.A. MEDICAL JOURNAL
the history and the fact that placental tissue was felt
vaginally it was thought that there must be some portion
of the placenta in the lower uterine segment. The dis-
a
covery of succenturiate lobe in this position revealed the
cause of the severe ante-partum haemorrhage despite the
presence of the main placental mass on the anterior wall
of the uterus. Kerr and Moir (1949) point out that in
placenta succenturiata, post-partum haemorrhage may
occur if the succenturiate lobe is left behind but they do
not mention this condition as a cause of ante-partum
haemorrhage. Siegler and Sacks (1941) describe a case
of placenta praevia with placenta succenturiata which
presented as an ante-partum haemorrhage, where the diag-
nosis was made by Ceasarean section. They reported
that they had not heard of a similar case but Torpin and
Hart (1941) published a series of cases of placenta bilobata
in which several presented as ante-partum haemorrhage.
TORSION OF A PYOSALPINX
ALLAN B. SWARBRECK,
Johannesburg
Since the advent of chemotherapy pyosalpinx has become
a disappearing disease and so the occurrence of its com-
plications less frequent. A case in which torsion occurred
is here recorded. Tubal infection is almost invariably
bilateral and an acute state, unless adequate treatment is
instituted, lapses into a chronic condition. In this case
symptoms and signs of an emergency arising from a
chronic condition were present. Torsion of a pyosalpinx
is rare because in nearly all cases the tubes become
adherent and fixed to surrounding structures, particularly
omentum and intestine: in fact, on this account removal
of a pyosalpinx may be fraught with the greatest difficulty
and tax the skill and dexterity of the most experienced
operator.
A. D., aged 21 years, an African negress, was admitted
to Edenvale Hospital on 13 April 1953.
Complaint. Lower abdominal pain for the past 2 days.
History. The pain was of sudden onset, at first cramplike,
later becoming constant and more severe; did not radiate
and much worse on the left side; there was some nausea
at the onset. For several months past there had been a
thick vaginal discharge and burning on micturition but no
frequency; there had been no recent exacerbation of these
latter symptoms. The bowels had acted twice spon-
taneously since the onset of the pain.
Menstrual History. Menarche at 13 years of age; kata-
menia regular, 5/28; no dysmenorrhoea. The last men-
strual period had commenced on 8 February 1953, i.e.
9 weeks previously. Nine days before, slight vaginal
bleeding started and lasted for 2 days.
Obstetric History. In March 1952 she had been delivered
by Caesarean section of a full-time living child: no details
were available as to what was the indication for abdomi-
nal delivery. but it was probably for cephalopelvic dis-
proportion.
CLINICAL FINDINGS
A well-nourished adult negress who looked acutely ill. No
pallor of the oral mucosa or conjunctivae. Temperature
99.8° F. Blood pressure 130/7-5 mm. Hg. Pulse-full
5 September 1953
The shocked state of the patient on admission was
probably due to a journey of some 50 miles which she
had made in an old lorry from a Native Reserve. On
the way to hospital she may have lost a considerable
amount of blood but her relatives were very vague about
the whole affair and no satisfactory explanation could be
obtained as to why they were so long in bringing the
patient to hospital.
Thanks are due to Dr. D. M. Blair, O.B.E., M.D., Acting
Secretary for Health, Southern Rhodesia for permission to
publish this case.
REFERENCES
Kerr, J. M. and Moir, J. C. (1949): Operative Obslelrics, 5th
ed., p. 668. London: Bailliere, Tindall & Cox.
Siegler, S. L. and Sacks, J. J. (1941): Amer. J. Obstet. Gynec.,
41, 901.
Torpin, R. and Hart, B. F. (1941): Amer. J. Obstet. Gynec.,
42, 38.
M.R.C.O.G.
volume, rate 120 per minute. There were no abnormal
findings in the central nervous, cardio-vascular or respira-
tory systems.
Abdomen. No distension or visible peristalsis: a firmly
healed transverse incision at the level of the anterior
superior iliac spines: the upper abdomen moved freely
with respiration. On palpation there was slight tenderness
in the right iliac fossa and marked tenderness in the left
iliac fossa. There were no palpable tumours and no exter-
nal herniae.
Vaginal Examination. Per speculum was seen a nulli-
parous cervix with a small congenital erosion of the exter-
nal os. There was some thick yellow discharge in the
vagina but no reddening of the external urinary meatus or
Sanger's macules.
On bimanual examination was felt:
(1) a small anteverted uterus, attempts to move which
caused agonizing pain;
(2) in the pouch of Douglas, a sharply defined mass,
the size of a golf ball and the consistency of india rubber,
which was not tender;
(3) on the left side, above and behind the uterus, an
exquisitely tender mass, the size of a tennis ball and seem-
ingly fixed to the posterior wall of the pelvis.
The urine showed no abnormal constituents.
DIAGNOSIS
In the differential diagnosis the following conditions were
considered :
(1) A lesion of the alimentary tract, e.g. perforation,
occlusion or thrombosis: these were excluded because of
the absence of vomiting, the pain had remained localized,
the bowels had acted since the onset of symptoms and
there was no rigidity or abdominal distension.
(2) A urinary tract lesion: this was excluded because
the pain had remained localized and no abnormal con-
stituents were found in the urine.
(3) A tumour of each ovary with torsion of that on the
left side: this would not account for the amenorrhoea,