A review of 268 ectopic pregnancies

A review of 268 ectopic pregnancies MORTON A. SCHIFFER, M.D. Brooklyn, New York

series, 34 per cent of our patients were Negro. Amenorrhea. Amenorrhea lasted from 1 to more than 16 weeks. Fifty-three patients had amenorrhea for 8 weeks. Ectopic pregnancy would be considered late after 12 weeks of amenorrhea; there were 34 or 13 per cent such cases in our group. Six patients had amenorrhea of more than 16 weeks' duration. Thirty-four had amenorrhea of 4 weeks or less. Frequently, with this short period of amenorrhea, the patients described some irregularity of periods or intermenstrual bleeding in the preceding 4 to B weeks. This emphasizes the need for very careful history taking, with close scrutiny of the menstrual cycle. Parity. Ninety-five or 35 per cent of the patients were nulliparous and 160 were parous. Twelve individuals were of unknown parity. In the parous group, there were 90 patients who had 1 child only and 21 with 3 or more children. Symptoms. The symptoms of ectopic pregnancy are varied and nonspecific. The subjective pain as described by the patient, mainly abdominal~some vaginal, rectal, and shoulder--accounted for the largest number. Pain was recorded in the histories of 252 patients. Bleeding was reported 202 times in the form of staining, spotting, or bleeding. There were 34 subjects who complained of pain with no bleeding. Thirtyeight patients manifested bowel or urinary symptoms either as tenesmus, dysuria, or rectal pain. Fainting was noted in 22 of the histories. Findings. One hundred and one individuals reported abdominal tenderness in vary-

E c T o P r c pregnancy has persistently remained in the maternal mortality statistics. In New York City, during the years 1951 through 1959, the ectopic maternal mortality rate varied from 3.9 to 11.9 per cent of the total. There were 920 maternal deaths, 85 or 9.2 per cent being attributed to ectopic pregnancies. Table I demonstrates these figures. The above statistics have been confirmed by other investigators/· 4 • 7• 10 The number of ectopic gestations is increasing each year, with a decreasing mortality rate. Despite this, the percentage of ectopic deaths in relation to all maternal deaths is increasing. Material

The material presented includes a series of 268 consecutive cases of ectopic pregnancy from the Jewish Hospital of Brooklyn. These cases were collected during the years 1950 through 1959, inclusive. There were no deaths. In this same period, there was a total of 47,211 births giving a ratio of 1:176. Age. The ages of the patients in this study ranged from 20 to 44 years. The largest number being in the 20 to 34 year age range. None were less than 20 years of age. Of interest are the 17 patients aged 40 to 44 years. Race. One hundred and seventy-four patients were white and 89 were nonwhite. The race of 5 was unknown. Nonwhite women comprised 32.8 per cent of the obstetric population in our hospital. In this From the Department of Obstetrics and Gynecology of the jewish Hospital of Brooklyn, and the Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center.

264

Ectopic pregnancies 265

Volume 86 Number2

ing degrees, usually in the lower abdomen. One hundred and fifty-two subjects were found to have a mass in the adnexa (120) or in the cul-de-sac (32). Twenty-one patients were in shock on admission. There were 78 or 29 per cent of the patients reported as having 500 mi. or more of blood loss. Temperature elevation was not a prominent finding, in only 1 individual was the temperature elevated to 101° F. and in 5 patients the temperature was elevated to 100° F. or more but less than 101. Bilateral masses were present in 58. Pelvic tenderness alone or with motion of the cervix was present in many of the cases. Eight had no abnormal findings and in 3 subjects, an abdominal mass was palpated. Cullen's sign was present in only 1. Diagnosis. The correct diagnosis was made on admission in 161 cases or 60 per cent. The number diagnosed as ectopic pregnancy, operated upon, and found to have other conditions is not available. Most of the diagnoses involved the pelvis. The largest number of incorrect diagnoses were made in the abortion, pelvic inflammatory disease, and ovarian cyst group which numbered 69, or 26 per cent. Eight cases were diagnosed as leiomyoma uteri. Three patients were thought to have intrauterine pregnancies. One was diagnosed as having endometrial polyps, and another was thought to have a ruptured uterus. Three individuals were listed as having ruptured corpus luteum cysts and 7 were operated upon for appendicitis. A ureteral stone was believed to be present in 1 patient. Five cases were diagnosed as dysfunctional bleeding, and 1 each as enteritis, blood dyscrasia, endometriosis, ovarian carcinoma, and intestinal obstruction. Two patients were thought to have pyelonephritis and no diagnosis was listed in 2. Past history and etiology. The past history may be of significance in predisposing to ectopic pregnancy. Sterility, which was noted in 24 cases, may have some direct relationship to the ectopic pregnancy. Possibly there were more cases of sterility not found in the histories.

There were 22 cases of inflammatory disease. It has been fairly well accepted that this disease predisposes to ectopic pregnancy.t· 12, u Seventeen of the patients had previous appendectomy and curettage was performed on 28 for incomplete abortion, induced abortion, or postpartum bleeding. Twenty-eight of the subjects had a previous ectopic pregnancy, and there were 45 who had known abortions. Five had previous cesarean section and 1 patient had had puerperal sepsis. In addition to the sterility group mentioned above, there was 1 patient treated with hormones for a hypoplastic uterus; 1 individual had irradiation therapy for infertility; 5 subjects who had dysfunctional bleeding were treated with cyclic hormonal therapy, and 1 patient was listed as "hypothyroid endocrine hirsute type." There were also 3 patients with a previously performed thyroidectomy. In view of some recent work 11 demonstrating the slowing of the passage of the fertilized ova in rabbits with the predominance of estrogenic hormone, these endocrine problems may possibly have some relationship to the development of ectopic pregnancy. There were other factors involved such as 3 previously performed oophorectomies, 2 myomectomies, 2 prior sterilizations, 5 salpingectomies, and 1 non-Neisserian peritonitis. Inflammatory disease is not always considered as the prime etiological factor in ectopic pregnancies. 11 Transmigration of the ovum is of some significance in the causation of ectopic preg· Table I

Year 1951 1952 1953 1954 1955 1956 1957 1958 1959 Total

% 8.3

8.5

11.4 11.4

10.1 9.6

10.2

3.9 9.6

9.2

May 11. 196:1 Am. J. Ob,t. & Gynec.

266 Schiffer

Table II. Endometrium ---------·I

Dilatation and curettage Decidual cast Endometrial biopsy Hysterectomy Total Decidual Proliferative Secretory Atypical Menstrual Endocervical No description Total

No. of

Patients

%

75 5

27.9 1.9

I)

17

n.o

--

6.3

23

8

:25.8 24.7 31.4 6.7 1.1 1.1 8.9

89

33.2

97

22

28 6 1 1

nancy. 3 There were 91 salpingo-oophorectomies performed in this series, 21 of these had no corpus luteum. If one can assume that not obtaining a corpus luteum in a salpingo-oophorectomy means that a corpus luteum is in the opposite ovary, there was an incidence of 23 per cent of contralateral corpora lutea in the 91 patients treated by salpingo-oophorectomy. Diagnostic procedures. The diagnostic procedures used showed a change in the second half of the 10 year period with an increase in the use of culdoscopy from 4 to 28 times. Culdocentesis was used on 11 occasions in the second 5 year period as compared to only twice in the earlier 5 year period. Dilatation and curettage was performed 31 times in the first 5 year period and on 44 occasions in the second half of the study. Colpotomy has shown no particular increase in usage. Biologic pregnancy tests were used more frequently, 57 times in the second 5 year period as compared to 30 times in the first half. There was a total of 239 diagnostic procedures. There was a total of 113 biologic pregnancy tests recorded. Six were negative prior to admission and 27 were positive prior to admission. Of the tests performed after admission, 14 were negative, and 49 were positive. There were 17 multiple tests. Of the 6 patients with a negative preg-

nancy test prior to admission, 3 were diagnosed as ectopic pregnancies on admission and 3 were not. Of the 27 subjects with a known positive pregnancy test prior to admission, 18 were admitted with a diagnosis of ectopic gestation and 7 with a diagnosis of pregnancy. Two had other diagnoses. Colpotomy' was used 22 times and one of the salpingectomies was performed through a colpotomy incision. Twenty-two or 8.2 per cent of our patients had colpotomies. Three colpotomies, 13.6 per cent, failed to give positive information. Two of the positive colpotomies followed culdocentesis failures. Culdocentesis has been frequently described as a very helpful diagnostic procedure in ectopic pregnancy. 9 • 13 Culdocentesis was performed on 13 or 4.8 per cent of our patients. Three or 23 per cent were negative. Two of the 3 failures were followed with colpotomies at which time the involved oviduct was visualized and the diagnosis made. Culdoscopy was carried out in 32 or 12.0 per cent of the patients. There were 6 ( 18.7 per cent I failures. It would seem with failure rates of 13.6 per cent with colpotomy, 23 per cent in culdocentesis, and 18.7 per cent in culdoscopy that a negative test should not be the determining factor in ruling out the possibility of an ectopic pregnancy unless all clinical factors are in agreement. Dilatation and curettage is of help in many cases although the possibility of inadvertently curetting an intrauterine pregnancy must be kept in mind. There are no such cases recorded here since the final diagnosis would be other than tubal pregnancy and, hence, the patient would not be included in this series. There were 75 curettages and 17 hysterectomies performed in this group of ectopic pregnancies. Several of the patients with hysterectomies had curettages performed prior to operation. In addition, there were 5 who spontaneously passed decidua. There was a total of 89 endometria available for pathologic study. In this group of endometria, 23 cases were reported as decidua, 22 were proliferative

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Ectopic piegnancies 267

Number 2

and 28 were secretory. 18 Six were noted as having atypical nuclear changes. There was 1 case of menstruating endometrium, 1 contained endocecvical tissue, and 8 endometria were not described. One was described originally as adenocarcinoma of the endometrium and previously reported by Mackles and co-workers. 15 This patient had a hysterectomy performed and was found to have an ectopic pregnancy. On review of the endometria, it was found to have a marked Arias-Stella reaction. 15 Table II lists the types of endometria and the means by '\vhich they were obtained. Previous ectopic pregnancy

There were 28 patients ( 10.4 per cent) with a history of a previous ectopic pregnancy. Others12 • 15 • 20 have reported percentages ranging from 5 to 11. When examining the incidence of repeat ectopic pregnancy, there were some facts which might be of significance. Five patients had histories of sterility. Five had known pelvic inflammatory disease and 3 had had a previous appendectomy, a questionable etiological factor. One patient had a second ectopic pregnancy shortly after undergoing hysterosalpingography. Nineteen of the patients had previous abortions, 10 were nulliparous and 9 who had had a previous abortion were parous. Fifteen individuals were without any history suggesting a relationship to repeated ectopic pregnancy. The treatment of the second ectopic pregnancy was salpingectomy in 15, salpingooophorectomy in 6 cases, hysterectomy in 2 cases, and conservative procedures in 4; in 1 the treatment was not known. Treatment. The treatment of ectopic pregnancy is surgical, the main purpose being to effect suitable hemostasis and to remove the pregnancy. Table III lists the operative procedures used and also any secondary operations. There were 151 salpingectomies, 91 salpingo-oophorectomies, and 17 hysterectomies performed. Eight patients were treated conservatively after 1955. One case had a salpingectomy performed through a colpotomy incision.

The conservative procedures carried out included salpingostomy in 5 instances. Stripping of the tube was performed in 3 instances. Three of the subjects treated by conservative procedures have been followed. One of these had 2 living children and had had a previous ectopic with salpingectomy 1 year prior; the contents of the tube were stripped out. This patient had been seen, but no hysterosalpingography has been performed and no pregnancy has occurred. Two other patients with conservative procedures performed and a known follow-up were both nulliparous and both were treated by salpingostomy and hemostasis only. The postoperative hysterosalpingography on both patients revealed normal uteri with bilateral patency of the tubes; both have become

Table III. Operative procedures 1

11"./o. of Patient< Salpingectomy Salpingo-oophorectomy Hysterectomy Conservative plastic

152 91 17 8

Total

268

Secondary procedures Myomectomy Opposite salpingectomy Ovarian resection Ovarian resection opposite Cornual resection (stump) Appendectomy Ligation

% 56.7 33.9 6.3 2.9

12 2

4.5 4.1 4.1 2.6 0.4 4.5 0.7

56

20.9

12 11 11

7 1

Total

Table IV. Hysterectomies No.

of Indication

patients

Type of operation*

Parity

Age Previous ectopic Interstitial pregnancy

4

2 3

0,0 0, 1, 1

T-a~~

........ ~-~.~-· U.l0311'Ca.o3C: ...1! ........... ~ ~IH.la.u.H.uct.L-u.ty

4

Leiomyomas Adenocarcinoma Agenesis of tube

2 1 1

""· .1, .:., .1

Total

17

*T, total; S, supracervical.

.:::,

n

., n ~, .:::,

')

1

2, 2 2 1

')

1

1

1

'T",.,...

'T"

C't

~' 1' 1'.:)

S, T S, T, T CC.T"r u, u, ~,

T,S

s s

~

268 Schiffer

pregnant and have been delivered of fullterm babies. In both instances, there was a normal uninvolved tube on the side opposite the ectopic pregnancy. Conservative procedures have been reported in the literature with more frequency but with only small degrees of successY• ~ 2 Seventeen hysterectomies were performed. Three of these were carried out primarily for an ectopic pregnancy, that is, for an interstitial pregnancy. Two of these individuals were parous and 1 was nulliparous. Four of the patients had hysterectomies performed because of age, each being 41 years of age or more and parous. Two of these women were treated for a second ectopic pregnancy, both were nulliparous. There were 4 patients with chronic inflammatory disease of the opposite tube; each was parous. Two of the parous subjects with leiomyomas had the uterus removed. One patient previously mentioned with an incorrect diagnosis of adenocarcinoma of the endometrium which was later recognized as a strong Arias-Stella reaction was treated by hysterectomy; she was parous. One parous individual was reported as having "agenesis of the opposite tube and ovary," the uterus was also removed. Nine of the hysterectomies were total and 8 were supracervical. The latter group had hysterectomies performed in the earlier part of the study. Table IV gives a list of these. Secondary to the primary procedure, there were a number of other operations performed. These included 2 myomectomies of varying number in each case, but of minor extent in all. Eleven patients had salpingectomy of the opposite tube and there were 18 who had partial ovarian resections, 7 of which were of the opposite ovary. There were 12 appendectomies and 2 ligations of the opposite tube. The 12 appendectomies and the 12 myomectomies were performed with no untoward effects. 21 Routine appendectomy is not advocated but certainly observation and extirpation of the appendix may be done where no extensive dissection is required and the general condition of the patient

Am.

J.

May 15, !963 Obst. & Gyn~c.

warrants the added procedure. Myomectomy, resection of ovarian cysts where necessary, may be advocated, but in the presence of marked blood loss and shock where time is of the essence these procedures would not be carried out. Anesthesia. Contrary to general opinion we have used spinal anesthesia in 116 patients with no unfavorable results. Inhalation was used 150 times and there was no record of anesthesia in 2. Time of operation. One hundred and forty-one patients were listed in this group as those being operated upon immediately ( 1 to 8 hours after admission). Fifty three patients were operated upon after 1 day, 21 on the second day and 19 on the third day of hospitalization. There were 30 subjects operated upon after the third day: 19 of these procedures were performed after more than 5 days. In 4 cases the period of hospitalization time prior to operation is not known. Transfusions. One hundred and eight patients were given no blood transfusions and 63 received only 1 unit of blood. Ninetyseven patients were given more than 1 unit, 14 of these received more than 4 units each. Complications. There were few complications in this series, only 27 cases or 10 per cent showing any complications. The largest group ( 17) had temperature elevation. In addition, there was 1 individual with bacteriuria. and 1 with thrombophlebitis with embolization and pulmonary infarct. There were 2 cases of intestinal obstruction. 1 nonsurgical and 1 requiring surgical intervention. One patient developed coronary insufficiency and 1, bronchopneumonia. Cardiac failure developed in 1 and another was readmitted with a pelvic hematoma which was treated by colpotomy and drainage. Comment

Ectopic pregnancy continues to be a factor in maternal mortality, being reported as being 6 to 9 per cent of the total. The mortality rate in ectopic pregnancy itself is 1 to 2 per cent with more and more large series being reported with no deaths. The mortal-

Volume 86 Number 2

Ectopic pregnancies

ity rate seems to be associated with a lower socioeconomic group having poor or inadequate medical care. The diagnosis of ectopic pregnancy is not always made when the patient is first seen. The admittance diagnosis was correct in 60 per cent of the present series. All diagnostic aids available should be resorted to in an attempt to make a correct diagnosis. Pregnancy tests, culdocentesis, colpotomy, culdoscopy, and curettage should be used with full recognition of the very definite failure rate associated with each of these procedures. Exploration should be carried out when the clinical suggestion of ectopic pregnancy remains despite equivocal or negative diagnostic tests. Curettage should be used judiciously to avoid unwittingly curetting an intrauterine pregnancy. The incidence of repeat ectopic pregnancies is high and consideration must be given to this fact when managing a patient with a history of a previous ectopic pregnancy. There are other factors in the history such as previous inflammatory disease, infertility, and laparotomy. Abortion and curettage or both seem to be associated with the incidence of ectopic gestation. The association may possibly be on the basis of inflammatory reaction in the tubes secondary to the abortion or curettage. If abortion, curettage, manual exploration of the uterus, and other intrauterine manipulation can be considered significant in the causation of salpingitis, these factors may be of some significanee in the cause of an ectopic gestation. The treatment of an ectopic pregnancy is

REFERENCES

l. Anderson, G. W.: AM.

61: 312, 1951.

J.

0BsT.

& GYNEC.

2. Beacham, W. D., Collins, C. G., Thomas, E. P., and Beacham, D. W.: J. A. M. A. 136: 365, 1948. 3. BerEnd, W.: Obst. & Gynec. 16: 51, 1960. 4. Chenoweth, A. D.: American Association for Maternal and Infant Health, Inc., 1960, p. 8.

5. Collins, C. G., Beacham, W. D., and Beacham, D. W.: AM. J. 0BST. & GYNEC. 57: 1144, 1949.

269

hemostasis and evacuation of the pregnaney. Blood replacement is essential; this combined with prompt operation will further reduce the mortality. In the light of presentday surgery, despite the low incidence of later intrauterine pregnancy and the threat of recurrence, conservative procedures on the affected tube in properly selected eases may well be performed. Incidental procedures such as appendectomy, myomectomy, and resection of ovarian cysts, were performed in selected subjects in the present series without increasing the morbidity or mortality.

Conclusions 1. Two hundred and sixty-eight cases of ectopic gestation are reported. 2. There was no mortality. 3. The medical history was the principal factor in establishing the diagnosis. 4. The initial diagnosis was" correct in only sixty per cent of the cases. 5. The cause of an ectopic pregnancy is related to inflammatory disease, transmigration of the ovum, abortion, previous curet· tage, and endocrine factors. 6. Culdocentesis, colpotomy, culdoscopy, eurettage, and biologic pregnancy tests are have a failure rate. diagnostic aids, but 7. Ectopie pregnancy was a recurrent condition in 10.4 per cent of the cases in this senes. 8. The morbidity was low in this series and secondary procedures such as appendectomy, myomectomy, and ovarian resection did not seem to cause an increase.

all

6. Collins, C. G., et al.: Bull. Chicago M. Soc. 54: 357, 1951. 7. Donovan, W. H.: Obst. & Gynec. 7: 694, 1956. 8. Draa, C. C., and Baurn, H. C.: AM. J. 0BsT. GYNEC. 61: 301, 1951. 9. Dunihoo, D. R., and Masters, W.: Minnesota Med. 42: 1768, 1959. 10. Fontanilla, J., and Anderson, G. W.: AM. J. 0BST. & GYNEC. 70: 312, 1955. 11. Greenwald, G. S.: Fertil. & Steril. 12: 80, 1961.

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1'-,

13. 14. 15. 16. 17. 18.

Schiffer

Henderson, D. N., and Bean, J. L. M.: AM. OssT. & GYNEC. 59: 1225, 1950. Hibbard, L. T.: Obst. & Gynec. 7: 453, 1956. Johnson, C. G., and Post, L. I.: Surg. Gynec. & Obst. 98: 481, 1954. Mackles, A., Wolfe, S. A., and Pozner, S.: AM. J. OssT. & GvNEC. 82: 1209, 1961. Malkasian, G. D., Jr., Hunter, J. S., and ReMine, W. H.:]. A. M. A. 168: 985, 1958. Osiakina-Rojdestvenskaia, A. J.: Surg. Gynec. & Obst. 67: 308, 1938. Romney, S. L., Hertig, A. T., and Reid, D.

l

Am.

J.

M") 15, l'lhi Obst. & Gynec.

E.: Surg. Gynec. & Obst. 91: 605, 1951. 19. Rosenblum, J. M., Dowling, R. M., and Barnes, A. C.: AM. ]. OssT. & GY:-;Ec. 80: 274, 1960. 20. Sandmire, H. F., and Randall, J. H.: Obst. & Gynec. 14: 227, 1959. 21. Schreier, P. C., and Myers, J. D.: South. M. ]. 53: 359, 1960. 22. Tompkins, P.: California M. ]. 88: '27, 1958. 100 Eighth Ave. Brooklyn 15, New York