The View from the Vue (18 page)

So, because he was in a hurry, my senior resident also failed to make the diagnosis, and I learned another valuable lesson: never trust anybody.

The remainder of Mrs. Cowens’ pregnancy was relatively uneventful, although she did continue to suffer from periodic attacks of pain and gastrointestinal upsets. On a few occasions she was on the verge of calling the hospital, but the symptoms disappeared as suddenly and as mysteriously as they had arrived. She kept all her weekly appointments with me, at which times I gingerly examined her abdomen and assured her that the baby had not changed its manner of presentation. About three weeks before her due date, with the baby still lying transversely, I told her that there was only a slight chance that it would convert to a normal longitudinal lie, and that a caesarean section would be necessary to deliver the child safely. I made certain she understood that she was to report to the hospital immediately upon the onset of labor.

Six days later, Mrs. Cowens was wheeled into the labor and delivery area at The Vue. She told us she had been awakened from sleep by cramping pains in her abdomen, superimposed upon which were frequent, violent movements on the part of the baby. Doubled over, she had half-crawled, half-walked into the bathroom, and vomited explosively into the toilet. When she had finished, she walked carefully back to the bedroom, woke up her husband, and told him she thought they’d better go to the hospital. By the time they arrived, her pain had greatly intensified.

I examined Mrs. Cowens, and saw no reason to alter my original diagnosis. It merely seemed that she was in labor, and perhaps a bit on the nervous side. So I gave her an injection of Demerol and Phenergan to ease her pain and calm her down, and then called up the senior resident to tell him we had a transverse lie in labor who needed a caesarean section.

At that point Mrs. Cowens’ luck took a turn for the good. My senior resident on call that evening was Vincent Ciccone. Vince was well known at The Vue as an intense worker and an extremely conscientious and knowledgeable doctor. His compulsive behavior was a perpetual source of exasperation to the rest of the residents, but we had to admit that it was also at times responsible for the successful outcome of a particularly difficult case. Most of the seniors would have told me to prepare the patient for surgery and then to call back when everything was ready. Vince came immediately to the labor suite.

When he arrived, he found Mrs. Cowens writhing on the examining table. He frowned as he touched her rigid abdomen, and she screamed in pain. His frown deepened as he did a pelvic examination and noticed the abnormally situated cervix. He made certain that she was not bleeding, and then, by checking her blood pressure, pulse, and general appearance, satisfied himself that she was not in shock. He listened to the loud, regular fetal heartbeat, and concluded that the baby was all right, at least for the moment. “But this isn’t any ordinary transverse lie,” he said tersely. “Get some blood for emergency cross-match, and then let’s take her down to X-ray. Maybe that’ll show us what’s going on.”

A half an hour later we were staring at an X-ray view box. Vince pointed toward the radiograph. “Look,” he said. “The fetal spine is very poorly flexed, and the arms and legs aren’t well folded at all. In fact, they’re sticking out in all different directions. Give you any ideas?”

I shook my head.

“Okay, let’s get a lateral view,” said Vince.

As we put the lateral film up onto the view box, Vince actually jumped up and down. “That just about clinches it,” he hollered.

I stared at the film, utterly mystified. I couldn’t even think of an intelligent question to ask.

“Look at the X-ray, Larry,” snapped Vince. “The baby’s bottom foot is overlapping the mother’s spinal column.

“But that’s impossible—if the baby’s inside the uterus,” I said slowly.

“Aha,” Vince crowed. “And look here. There’re all kinds of loops of intestine intermingled with the baby’s body.”

In his agitation, Vince almost shoved me back into the X-ray room. Mrs. Cowens was lying on the table on her side, clutching her abdomen, with her legs drawn up as far as her distended belly would allow. We helped her to turn onto her back, and then Vince gently inserted a thin metal probe through the cervix into the uterine cavity.

“Doesn’t go terribly far at all,” he said, giving me an affirmative nod.

The technician snapped a side view of Mrs. Cowens’ abdomen. As the film came out of the developer, Vince grabbed it and thrust it up onto the viewing screen. He punched me firmly on the arm. “How does that grab you?” he shouted.

“I’ll be damned,” I mumbled. I couldn’t stop gawking at the X-ray, which clearly showed the probe extending up into a uterine cavity whose small extent obviously could not contain a full-term pregnancy. Above and behind the probe, clearly separated from it, lay the fetus.

I finally turned around to look at Vince, but he wasn’t there. He had gone across the room and was talking on the phone, gesticulating emphatically at the mouthpiece as he spoke. I walked toward him, and as I did, I heard him tell Dr. Allen Bean, our attending physician, to come right in and help him operate on a case of advanced abdominal pregnancy with a living fetus.

Most laymen are acquainted with the term ectopic pregnancy which they equate with a gestation in the fallopian tube. For the most part they’re right, but all ectopic pregnancies are not tubal. Strictly speaking, an ectopic pregnancy is one which is located outside the uterine cavity. Aside from the tube, the pregnancy may be situated in the ovary, the uterine cervix, or the abdominal cavity. In most American localities, one out of every hundred to two hundred pregnancies is ectopic. Ovarian and cervical gestations account for only a tiny number of these, while the incidence of abdominal pregnancy is about 1:3500.

Quite understandably, throughout history, abdominal pregnancy has been a source of amazement and wonder to lay and medical observers. The Talmudic rabbis recorded the case of a child “which emerged from the abdominal side of the mother.” Adherents to the Buddhist faith believe that their spiritual leader “was born through the right side or the armpit of his mother.”

The first authentic recording of an abdominal gestation, however, is generally attributed to Albucasis, the famous Arabian physician who practiced in Cordova in Spain during the tenth century
A.D.
Albucasis described the case of a woman whose fetus had died undelivered, and who then conceived a second time. This fetus also died without being expelled. After an interval, an abscess appeared at the umbilicus which, upon rupture, exuded pus and two small bones. Astonished, the physician probed the abscessed cavity and extracted numerous bones, which he thought belonged to the two fetuses. The woman eventually recovered.

Many obstetrical historians believe that the first case of surgery for abdominal pregnancy with survival of both mother and baby was that of Elizabeth Nufer. The operation supposedly took place in Sigershausen, Switzerland, in the year 1500. The patient had appeared to be in labor with her first child for several days, but remained undelivered despite the attention of numerous midwives. Her husband, Jacob, the village swine gelder, finally decided that enough was enough, and took matters into his own hands. Assisted by two of the more courageous midwives, he “placed his wife upon a table and made an incision in her belly, just as he would have done in the swine. He opened the abdomen so neatly with one stroke of his knife that the child was extracted at once without harm.” Both patients did amazingly well postoperatively.

Over the next four hundred years, European doctors performed and reported numerous operations for abdominal pregnancies, usually to remove retained dead fetuses, some of which had remained in place as long as forty-six years. Apparently, the first time a case of abdominal pregnancy came to surgery in the United States was in 1759, when John Bard operated on a certain Mrs. Stagg. The mother, but not the baby, survived.

With the passage of time, improved surgical techniques, the use of antibiotics, and matched blood transfusions have combined to lower the risk to the mother, though recently quoted modern maternal mortality figures of 6 to 15 percent are still high enough to inspire considerable anxiety in the mind of any obstetrician faced with such a patient.

The question arises as to the manner in which a pregnancy comes to develop in the abdominal cavity. Relatively few of these cases represent primary abdominal pregnancies, that is, where an egg, released from the ovary, falls into the abdominal cavity upon failure of the usually reliable tubal pickup mechanism. The felony is then compounded by a particularly enterprising spermatozoon, which traverses the entire length of the uterus and tube and passes into the abdomen, where it fertilizes the aberrant egg. The newly created embryo then does what comes naturally, sending its placental offshoots deep into the exterior of the uterus, the intestines, the bladder, the pelvic wall, or any other handy structure. In contrast, the majority of abdominal pregnancies are secondary, which means that they begin as the more common tubal type of gestation. Although most tubal pregnancies rupture, with massive and dramatic intra-abdominal hemorrhage, those destined to become abdominal pregnancies erode slowly through the wall of the tube, with little or no bleeding. Then, the placenta subsequently spreads out its attachments onto the surrounding pelvic structures while the fetus continues its development, essentially free in the abdominal cavity.

The exterior surface of the uterus, the intestines, and the peritoneal lining of the inner abdominal wall cannot supply nearly as hospitable an environment for the implanting and developing embryo as can the specialized uterine cavity. Therefore, in most cases of abdominal pregnancy, the abnormally situated placenta sooner or later reaches the limit of its impaired capacity to supply oxygen and nutrients to the fetus, which then dies. If this occurs early, the small fetus and placenta are broken down by the body’s natural defenses, and the products are absorbed via the blood stream. However, if the fetus manages to reach a size too large to permit reabsorption, then some of the most amazing and unusual situations in medicine may ensue. The fetus may undergo desiccation and calcification, with formation of a lithopedion (literally, “stone baby”). Some of these may be discovered many years later, at surgery, at autopsy, or when they block the birth canal during a subsequent labor. On other occasions, bacteria from the intestines may enter the dead fetus and cause formation of an abscess, which may then rupture through the abdominal wall (as in the case of Albucasis), or alternatively, into the bladder or rectum, with the ultimate passage of small bones by the urinary or the fecal route, a matter of much amazement and no little consternation to the passer and her physician. In probably no more than 5 percent of all abdominal pregnancies does the placenta eke out sufficient nutriment from its unlikely implantation site to support the growth of a fetus to viability.

Primarily because of its rarity, abdominal pregnancy often is not diagnosed until obvious signs of an intra-abdominal catastrophe force themselves upon the consciousness of the medical observer. From the beginning, Mrs. Cowens’ symptoms were quite typical of the disease.

Very commonly, the first sign of trouble is a bout of abdominal pain during the second or third month, often accompanied by light vaginal bleeding. This probably is the time at which the pregnancy is eroding through the tubal wall and into the abdomen. From that point on, abdominal pain, nausea, and vomiting are frequent and severe, as the placenta burrows away at whichever organ happens to be available, and as the fetus grows and moves among the loops of intestines. As was the case with Mrs. Cowens, the fetus usually seems to be carried higher than is normal, and frequently it assumes a transverse orientation relative to the mother, rather than the normal vertical lie, with head down. Because of the displacement of the empty uterus by the growing pregnancy, the cervix may occupy an abnormal position in the vaginal canal: Mrs. Cowens’ cervix was pushed forward, but depending on the location of the pregnancy, it might have been pushed backward or to the side. When this sign is recognized, sometimes the diagnosis can be made by feeling parts of the baby through the upper vaginal wall, next to the cervix, and therefore not within the uterus.

When abdominal pregnancy is thought probable, the diagnosis may be confirmed by the technique Vince Ciccone used. A metal probe placed within the uterine cavity will be seen on an X-ray to be adjacent to and separated from the fetus.

In point of fact, both Mrs. Cowens and her baby—but especially the baby—were fortunate that the doctor in the Houston emergency room was not more thorough and that I was not more experienced. Because of the very poor outlook for the baby, most obstetricians will operate to terminate an abdominal pregnancy as soon as the diagnosis has been made. To do otherwise is to run the risk that part of the placenta may separate from its attachments, producing massive, possibly fatal, hemorrhage. In addition, at surgery, unless the blood vessels supplying the placenta can be clearly identified and tied off, the placenta should be left in place after the baby has been removed. This will prevent the occurrence of heavy, unstoppable bleeding from the implantation site. In normal pregnancies, the post-delivery contraction of the uterine muscle fibers squeezes shut the huge blood vessels in the placental bed, preventing bleeding, but in abdominal gestation there is nothing to constrict the dilated arteries and veins after the placenta has been torn away from them. In contrast, when the abdominal placenta is left in place, it most often gradually reabsorbs, leaving just a small lump at the implantation site. Sometimes, however, the organ will become infected, producing an abscess. Or it may become painful, or even cause obstruction of the intestine. Any of these complications requires re-operation, but this is not as dangerous as the hemorrhage caused by separation of the placenta at the time of delivery of the child.

That was all I could think about as we wheeled Mrs. Cowens to the operating room. I wasn’t altogether grateful to Vince Ciccone for making me aware of the potential disasters that could have been visited on our patient. By that time her belly was so tender we couldn’t even touch it. I had made certain that the blood bank had six bottles of compatible blood ready to use and that they were getting even more ready. But now I knew that if there should be one wrong move at the operation, she would lose blood faster than we’d be able to run it in. I began to wish I had taken my elective in dermatology. Suddenly, it wasn’t so much fun to be a sub-resident in obstetrics.