Schmitt, Alexander H.

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The Linacre QuarterlyVolume 7 | Number 3 Article 2July 1939The Medico-Moral Problem RegardingHydramnios*Alexander H. SchmittFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationSchmitt, Alexander H. (1939) "The Medico-Moral Problem Regarding Hydramnios*," The Linacre Quarterly: Vol. 7 : No. 3 , Article 2.Available at: http://epublications.marquette.edu/lnq/vol7/iss3/2THE LINAORE QUARTERLY THE MEDICO-MORAL PROBLEM REGARDING HYDRAMNIOS* By ALEXANDER H. SCHMITT, M.D., F.A.C.S. New York, N. Y. Hydramnios is a condition in which an excessive quantity of li-quor amnii collects within the membranes. The average amount of fluid occurring in patients at term has been determined to vary frem 1000 cc. to 1200 cc. A quan-tity greater than 2000 cc. is usu-ally considered excessive, and amounts of 15 liters or more have been reported at the sixth month. While the chief factor responsible for this excessive production or retention of fluid is unknown, am-niotitis, deformity of the foetus and maternal toxaemia are con-tributing agents. Acute hydramnios complicating pregnancy at the fifth or sixth month is indeed rare, but when it does occur, we are faced with a moral problem as to treatment. Since the foetus is viable from the seventh month we will limit our discussion as to the propriety of rupturing the membranes at the fifth or sixth month, or before the time of viability of the child. Polyhydramnios arises early in pregnancy, and at the fifth or sixth month may give rise to severe pressure symptoms due to the rapid accumulation of fluid. Dysp-noea so severe as to absolutely preclude the patient's lying flat; IL.:~e two remarkable articles by Dr. '"""uwtt and Fr. Davis, S.J., respectively, •hould be Tead in conjunction with each otheT. cyanosis, oedema of the lower ex-tremities, with pain in back and abdomen are also present. The skin is under excessive tension, and the entire abdomen is hard and tense. Foetal parts are not palpable, nor are heart sounds heard. Extreme exhaustion, car-diac embarrassment and death of mother may follow. Thus we have a picture of a con-dition which r equires intervention, for if treated conservatively, a fatal outcome may ensue. What is the Catholic physician to do? In all text books on obstetrics we read that the treatment for acute hydramnios is active and consists of rupturing the mem-branes and allowing the fluid to escape. The patient is then left to a spontaneous miscarriage which almost always occurs. This operation, in my opinion, is a direct attack on the foetus, and it is fatal to it. Theolo-gians condemn this procedure, stating that the liquor amnii is necessary for the life of the foe-tus, and that the rupture of the membranes with the escape of all the fluid procures a direct miscar-riage. They explain their teach-ing in regard to the rights of the unborn child to life, even when it threatens the life of the mother. There is no other alternative but. to accept this decision and not rupture the membranes. How then [ 53 1 I ] I ;: I I I I THE LINAORE QUARTERLY can a Catholic physician success-fully manage such a case? Doctors Dieckmann and Davis, of the Chicago Lying-in Hospital, have carried on extensive studies on the nature and mechanism of formation of the liquor amnii in the human. In the course of these experiments it was necessary to puncture the amniotic cavity in late gestation in the normal women as well as in women with hydram-mos. From these studies Dr. Davis states that in acute hydram-nios it would be entirely possible to drain off a certain amount of amniotic fluid and have the patient continue with her pregnancy. I, therefore, suggest puncturing the amniotic sac through the ab-domen with a long needle or fine trocar and canula and drain off slowly by mild suction amounts of fluid varying between 850 to 3750 cc. The technic is simple and un-less the patient has extensive ad-hesions due to a previous opera-tion there is no danger of injuring the intestines, as the over-dis-tended uterus presses firmly against the anterior abdominal wall. The uterine cavity can best be entered five to six em. above the symphysis when the patient is on her back and the bladder com-pletely emptied. The right or left of the mid line is chosen, depend-ing on which side fluid is more easily palpable, and a local anaes-thetic is all that is necessary. The foetus in utero is not injured. If the puncture yields pure blood the needle is withdrawn and reintroduced higher up, as there is probably present a low-lying placenta which was pricked. The immediate results are always good because the pressure symptoms are relieved at once. To prevent labor pains morphine is given in small repeated doses after the op-eration. Dr. A. Mayer of Vienna reports twelve cases of hydramnios in which he punctured the amniotic sac through the abdomen at the fifth and sixth month. In five cases, labor followed in one, three, six, eight and ten days respec-tively, while the remaining seven continued on to near term. Drs. Dubrovsky and di Fonzo observed hydramnios in 209 preg· nant women out of a group of 38,500 who were cared for at the Maternity Hospital of Buenos Aires from 1928 to 1936. The ~ondition was of slow evolution in 162 cases and acute or subacute in forty-seven. In this latter group there were eight twin pregnancies. Twenty-six of the acute cases were carried to or near term. When-ever warranted, puncture of the uterus for elimination of hydram-nios was practiced. On all occa-sions it improved the condition of the mother. However, in about 50% it was followed by a spon-taneous miscarriage or premature delivery. I recently had one case at six months where percutaneous punc-ture for hydramnios was per-formed. The patient continued with her pregnancy until the sev-[ 54 I THE LINAORE QUARTERLY enth and one-half month when she delivered twins, but both died of prematurity within thirty-six hours. Rupture of the membranes through the cervix with an orange stick or other device is differ ent from puncturing the membranes through the abdominal and uterine wall with a fine needle or trocar. In the former there is no control over the amount of fluid which . escapes, in fact, all eventually is lost. In the latter procedure we can measure just how much fluid we wish to remove, leaving a suffi-cient amount necessary for the life of the foetus. This excessive amount of liquor amnii in hydram-nios is pathological, and it is only that amount which is removed in the uterine puncture. Dr. Davis has observed that there was absolutely no leakage of ~uid through the needle puncture ID the uterus. . Furthermore, since it was a simple procedure with ap-parently little risk to the patient, he concluded that abdominal punc-t?re of the uterine cavity was en-tirely feasible. To quote "In acute hydramnios it would be en-tirely possible to draw off a cer-tain amount of amniotic fluid and have the patient continue with her pregnancy. After some of the ftuid was withdrawn it would be well to have an x-ray picture of the foetus made in order to rule ?ut a possible monstrosity which l8 so often associated with this condition.'' In my opinion, therefore, this operation is not a direct attack on the foetus, as enough fluid always remains within the sac necessary for its life and growth. It does not procure a direct mis-carnage. In a recent book on "Moral and Pastoral Theology" by the Rev. Henry Davis, S. J., of Oxford, England, I found the following statement under the title of the Medico-Moral Problem Regarding Eclampsia-"But if a mother can be saved by a method which is the only one available, and which is not a direct atta~k on the · child, viable or not, although which may prove fatal to the child, the sur-geon is justified in operating." I believe that the procedure which I have here outlined belongs in this category. REFERENCES Monatschr f. Geburtsh u . Gynak. 104 :259-264, Feb. 1937; Prensa Medica Argentina, Buenos Aires; Hydramnios in the Clinic, R. Du-brovsky and N. 0 . di Fonzo; .M. J. Dieckmann and M. Edward Davis: Volumetric Determination of Amniotic Fluid with Congo Red, Am. J. Obst. & Gynec. p. 623, May, 1923; Rev. Henry Davis, S.J., Oxford, England: Moral and Pastoral Theology; Curtis, Ar-. thur H.: Obstetrics and Gynecol-ogy, 1933, Vol. 1, W. B. Saunders Co. ; Williams, J. William: Ob-stetrics, New York, 1930, D. Ap-pleton & Company. "[ lSlS 1 

The Medico-Moral Problem Regarding Hydramnios*

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The Medico-Moral Problem Regarding Hydramnios*

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