5 September 1953

TABLE

S.A. TYDSKRIF VIR GENEESKUNDE

773

m:

SUMMARY OF SERUM PROTEIN-BOUND IODINE RESULTS IN 46 PATIENTS

Final Clinical Assessmenr of Thyroid State
Hypothyroid Euthyroid Hyperthyroid

Serum PB] p.g. Number of Cases Range

%

Mean

5

0·6-2·2 2-0--7'7 6,7-24,0

1·3 4·7 11·3

23 18

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 B.M.R. de terminations, considering that these estimations 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)

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 membranes, pu'se of poor volume, rate 140 per minute, blood pressure 70/30, temperature 97.6° F with rapid respirations. 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

made and a 2-finger os was felt with placental tissue covering 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 dissection 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 postoperative convalescence was uneventful apart from a slight bronchitis from 20 to 22 November. She was discharged 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 bleeding after the transfusion of the blood prompted the carrying out of a Caesarean section, when the placenta was revealed as being on the anterior uterine wall. Because of

Complaint. no dysmenorrhoea. Thanks are due to Dr. J. 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. Tindall & Cox.R.. (1941): Amer. On palpation there was slight tenderness in the right iliac fossa and marked tenderness in the left iliac fossa. Blair. (3) on the left side. was admitted to Edenvale Hospital on 13 April 1953. 42. R. occlusion or thrombosis: these were excluded because of the absence of vomiting. the size of a golf ball and the consistency of india rubber. 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. London: Bailliere. 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. e. above and behind the uterus. unless adequate treatment is instituted. A.e. an African negress.. but it was probably for cephalopelvic disproportion. MEDICAL JOURNAL 5 September 1953 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. C. The last menstrual period had commenced on 8 February 1953. Obstet. slight vaginal bleeding started and lasted for 2 days. Southern Rhodesia for permission to publish this case.774 S. Siegler and Sacks (1941) describe a case of placenta praevia with placenta succenturiata which presented as an ante-partum haemorrhage. 668. Torsion of a pyosalpinx is rare because in nearly all cases the tubes become adherent and fixed to surrounding structures.C. L. 901. The pain was of sudden onset.A. SWARBRECK. M. there was some nausea at the onset. 9 weeks previously. Obstetric History.D. later becoming constant and more severe. Kerr and Moir (1949) point out that in placenta succenturiata. 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. aged 21 years. Gynec. 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. (3) A tumour of each ovary with torsion of that on the left side: this would not account for the amenorrhoea. O.B. the bowels had acted since the onset of symptoms and there was no rigidity or abdominal distension. Menstrual History. 41. there had been no recent exacerbation of these latter symptoms.g. (1941): Amer. did not radiate and much worse on the left side.O. On bimanual examination was felt: (1) a small anteverted uterus. The discovery 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.8° F. F. The bowels had acted twice spontaneously since the onset of the pain. TORSION OF A PYOSALPINX ALLAN B. a 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. rate 120 per minute. . Tubal infection is almost invariably bilateral and an acute state. the pain had remained localized. Siegler..E. M. Per speculum was seen a nulliparous cervix with a small congenital erosion of the external os. Blood pressure 130/7-5 mm. D. CLINICAL FINDINGS volume. J. 5th ed. In this case symptoms and signs of an emergency arising from a chronic condition were present. attempts to move which caused agonizing pain. There were no abnormal findings in the central nervous. Menarche at 13 years of age. the size of a tennis ball and seemingly fixed to the posterior wall of the pelvis. There were no palpable tumours and no external herniae. an exquisitely tender mass. M. REFERENCES Kerr. 5/28. J. There was some thick yellow discharge in the vagina but no reddening of the external urinary meatus or Sanger's macules. and Moir. J.. a sharply defined mass. No pallor of the oral mucosa or conjunctivae.. D.G. J. katamenia regular. Obstet. Torpin. Abdomen. perforation. which was not tender. and Sacks. particularly omentum and intestine: in fact. lapses into a chronic condition. The urine showed no abnormal constituents. M. 38. For several months past there had been a thick vaginal discharge and burning on micturition but no frequency. Nine days before. Johannesburg Since the advent of chemotherapy pyosalpinx has become a disappearing disease and so the occurrence of its complications less frequent. and Hart. (2) in the pouch of Douglas. Vaginal Examination. (1949): Operative Obslelrics. B. i. Gynec. where the diagnosis was made by Ceasarean section. DIAGNOSIS A well-nourished adult negress who looked acutely ill. 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 abdominal delivery.. History. S. (2) A urinary tract lesion: this was excluded because the pain had remained localized and no abnormal constituents were found in the urine. J. cardio-vascular or respiratory systems. Temperature 99. A case in which torsion occurred is here recorded. Hg. Lower abdominal pain for the past 2 days. Acting Secretary for Health. p. Pulse-full In the differential diagnosis the following conditions were considered : (1) A lesion of the alimentary tract. at first cramplike.

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