A five-year survey of ectopic pregnancy

A FIVE YEAR SURVEY

OF ECTOPIC PREGNANCY*

CHARLES W.

MUELLER,

M.D.

BROOKLYN, N. Y.

0

months each year, a total of fifteen months in aI1, there were admitted 40 cases of extrauterine pregnancy. One patient was moribund on admission and died very shortIy after, without treatment. Necropsy showed an advanced interstitia1 pregnancy ruptured from the cornu of the uterus, and a four-month fetus was found in the abdomen. This patient died of hemorrhage. Another case was one of advanced abdomina1 pregnancy which was discharged through error by an interne after an x-ray diagnosis of norma pregnancy. The patient was Iater re-admitted to the obstetrica service and died of peritonitis after having passed bIood frequentIy from the rectum, which showed the invasion of the intestina1 tract by the chorionic viIIi. The necropsy showed a six-month macerated fetus. These 2 cases are not considered in our report. This gives 38 cases of ectopic gestation that were consecutiveIy operated upon with no mortaIity.

UR present-day knowIedge of ectopic pregnancy as to etioIogy, pathoIogy and treatment is nearIy compIete, but diagnosis in a certain group of cases at times stiI1 remains diffrcuIt. This anaIysis, therefore, was undertaken with the view of stressing some of the signs and symptoms which aid in diagnosis. HISTORY

Extrauterine pregnancy was apparentIy unknown to the ancient Greeks or Romans because no aIIusion was made to the subject in their literature. About 1050, AIbucasis, an Arabian, described a condition which was apparentIy an extrauterine pregnancy, which, as far as we know, was the first case recorded. The first operation for extrauterine pregnancy was described by Dr. John Bard of New York, December 25, 1759. In 1883, onIy fifty years ago, Lawson Tait estabIished the operative treatment for the condition, the first patient dying, but he continued to use this method of treatment and reported a series of 40 cases with one death. However, most men of this era stiI1 continued to beIieve that extrauterine gestation was a grave condition and when it occurred they extended a11 reIief within the narrow boundaries of their power, and caImIy awaited and submitted to the inevitabIe end. In this period, Schauta reported I 2 I cases treated paIIiativeIy with a mortaIity of 86.6 per cent. Parry in 1876 reported 500 cases in which there were 386 deaths or 77.2 per cent. In the Iast five years on the service of Doctor Cameron Duncan, at the Kings which is but three County HospitaI, * From the GynecoIogical

ETIOLOGY

Most authors attribute tuba1 pregnancies to mechanica impediments to the norma progress of the ovum, such as inffammation and adhesions of the tubes, tumors, inflammation of the tuba1 mucosa, congenita1 tuba1 deformities, tuba1 spasms and externa1 migration of the ovum. May we add here that saIpingograms, as we11 as insufIIation of the tubes, may be a causative factor, but none of the cases in our series prove this point. HormonaI disturbance may prevent the proper deveIopment of the ovum and, the proper movement of the fertiIized ovum. had proved In our series, 2 patients Gonococci infections, 2 others gave aImost

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conclusive histories and another patient stated that her husband was suffering from an urethral gonorrhea1 infection. One patient had been septic foIIowing an abortion. Two patients were previousIy operated upon for extrauterine pregnancies. Two patients had an ectopic gestation folIowing non-infective abortions, and I 2 had had previous normaI pregnancies and also had suffered abortions. Therefore, 22 of the 38 patients had definite peIvic pathoIogy before an ectopic occurred. In onIy 3 patients pregnancy was the ectopic the first pregnancy. BaIus states that 28 per cent of his cases gave a history of gonorrhea1 infection. Potter reports 3 cases of ruptured ectopic pregnancies in which the patients were wearing a gold spring pessary for contraceptive purposes. The Iargest number of cases occurred among the muItiparas, but we found that as the parity increased the incidence decreased. Our histories were incompIete in many instances as to the patients who compIained of previous peIvic symptoms, hda previous peIvic operations, or previous appendectomies and previous menstrua1 disorders. The ages ranged from twenty to thirtybeing between eight years, 20 patients the ages of twenty and thirty, and 18 between the ages of thirty-one and forty years. and I I There were 27 white patients coIored patients, about our usua1 ratio of race admissions. The history of sterihty does not corroborate the usua1 idea, nameIy that a long period of sterility usuaIIy exists before the occurrence of an ectopic pregnancy. In our series, 26 patients gave the average period of sterility as three years, the Iongest period of sterihty being eIeven years. In Widan’s series, the average period was 3,9 years. SYMPTOMATOLOGY

Most constant

writers finding,

beIieve that pain is a most commonIy miId in

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character, distributed over the Iower abdomen, foIIowed by an acute attack; or, there may be repeated colicky attacks; or, IastIy, there may be a sudden, se\-ere, acute attack with or without previous symptoms. Thirty-six of the 38 patients complained of abdomina1 pain; in 3 cases, most severe, those of apparent extratuba ruptures. The remaining patients described the pain as sharp, knife-Iike, sticking, &icky, cramp-Iike and pressure-like. 0111~ a few compIained of shouIder or upper right quadrant pain, which is caused 69 a reflex arc estabhshed through the phrenic nerve when the centraI portion of the diaphragm is irritated by free blood in the abdomina1 cavity. IrreguIar bleeding was noted in 34 of the 38 cases, 89 per cent. Most commonIy, menstruation does not appear at the expected time, then a few days Iater there is a sIight spotting, but the Bon- is not freeIy estabhshed. At times, the spotting is accompanied by a discharge of uterine decidua, but this is usuaIIy described as cIots and not identified. Sampson, who recentIy studied the uterus in ectopic pregnancy, rather concIusiveIy proved that the bIeeding was of venous origin and therefore came from the endometria1 cavity and not from back pressure from the tubes. The symptom of dizziness was recorded in I I cases, that of fainting in 9 cases, nausea in 7 cases, urinary symptoms in 3 cases. Weakness, paIIor, fatigue and maIaise were reported occasionaIIJ-. There were 7 patients admitted in varying degrees of shock and the foregoing symptoms were more characteristic in this In severe shock, the diagnosis is type* easiIy made, frequentIy without the aid of a pelvic examination and is the type most frequentIy seen by the abdomina1 surgeon, whiIe the gynecoIogist must dea1 with those which occur before tubal or peritonea1 rupture, wherein the symptoms and findings may be most confusing.

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SYMPTOMS

Lower abdomina1 tenderness was as frequent as the symptom of pain, and was recorded in 36 cases. Rigidity of the recti muscIes was noted in 20 cases, 5g per cent; absent in 16 cases and not recorded in one case. Widan states that rigidity is rare, frequentIy confused with abdomina1 spasm, and is present onIy when the peritoneum is irritated by free bIood. PeritoneaI rebound was present in 26 patients, 67 per cent. FIuid wave or duIness in the flanks occurred in onIy one case. Watkins found that it was present in 735 per cent of his series. CuIIen’s sign, the bIuish discoIoration about the umbiIicus, was not noted. One writer noted its occurrence onIy 6 times in 1400 cases. Jaundice may occur after intraperitonea hemorrhage, resuIting from the absorption of the oId bIood (biIe pigment). Dumphy found this sign in 4 of his 40 cases. He states that the quantitative Van den Bergh and the serum biIirubin tests are usuaIIy we11 above normaI. These tests and the pyramidon test, that of hematin in the bIood serum, were not used in any of the cases in our series. VAGINAL

FINDINGS

I. Pain on IateraI or anterior-posterior motion of the cervix was present in Ig cases or 50 per cent, absent in 5 cases and not recorded in 14 cases. This finding is caused by the reaction of the peritoneum covering the uterosacra1 Iigaments, making them sensitive; hence, anything which moves them causes pain. 2. Softening of the cervix was present in IO cases or 26 per cent, norma consistency in 26 cases. This symptom is due to congestion consequent upon pregnancy. 3. Bleeding from the cervica1 OS was present in 24 cases, 60 per cent; absent in I I cases. 4. EnIargement of the uterus was pres-

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ent in I I cases, 28 per cent; absent in xg cases. Th e uterus shouId enIarge in cases which have progressed to the eighth week, the resuIt of the organ preparing for conception. However, the uterus shouId change onIy in size, not in shape, or show the other characteristic signs of pregnancy as the pregnancy is not contained within its waIIs. 5. Diagnostic masses were paIpabIe in 32 cases, and tenderness was present in one or both fornices in 35 cases. LABORATORY

DATA

The average red ceI1 count was between three and four miIIion ceIIs. The average hemagIobin was 72 per cent. In 60 per cent of the cases the white ceI1 count was 10,000 or Iess; in 40 per cent 10,000 or over. The Iowest white ceI1 count was 4000; the highest 30,100. The presence of bIood in the peIvic or abdomina1 cavity produces Ieucocytosis; therefore, the high counts were found in the tragic cases. The sedimentation time was determined in 2g cases. It was considered norma in 24 cases, forty-five minutes in one case, and rapid in 4 cases. One of these rapid cases at operation proved to be an oId tuba1 abortion, whiIe the opposite adnexa was the seat of a sub-acute inff ammatory process. Widan found that 20 per cent of his 44 cases showed a sedimentation time of Iess than thirty minutes. Five cases, however, proved to be hematoceIes, of which 2 were infected and one was associated with an acute appendicitis. This Iaboratory test has proved very successfu1 in our hands in aiding in the differentia1 diagnosis; nameIy, between extrauterine gestation and acute or subacute peIvic inffammatory disease. It must be remembered that the sedimentation time may become rapid after the third month of pregnancy, or in cases of marked anemia.

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On none of our cases were the AschheimZor.dek, Freidman or Mazer-Hoffman tests carried out. Frank recentIy reported observations on the Aschheim-Zondek test in I I cases, in which 8 gave positive reactions. One negative resuIt was obtained from urine coIIected two days after operation; another was ascribed to a compIete degeneration of the ectopic ovum; a third was Iaid directly to faiIure in the reaction. The death of the fetus does not affect the reaction as Iong as the Iiving products nameIy the chorionic viIIi, of conception, are retained. The femaIe sex hormone test gives a negative resuIt immediateIy foIIowing the death of the fetus. We advocate, and shaI1 in the future use, this vaIuabIe diagnostic aid in those earIy cases where rupture has not aIready occurred. The temperature is an uncertain finding. Most of the cases were reported as normaI; many were eIevated to 99.6” or IOO’F. which usuaIIy means peritonea1 irritation or absorption of the bIood or bIood cIots as the resuIt of rupture of the faIIopian tube. Three cases in our series had temperatures of IO I’F. or over, the highest being I 02’F. The bIood pressure findings are important, but most variations are usuaIIy found onIy in the grave cases after a considerabIe hemorrhage. The respiratory rate is no indication of the condition. Again, onIy in the grave case does it give us an index as to our true picture. The same is true for the rate and volume of the puIse. Brieff y, the varieties of ectopics are: (I) ampuIIar; (2) isthmic; (3) interstitia1; (4) tubo-ovarian; (3) abdomina1. To this cIass&cation may be added the tubouterine which is interstitia1 at the beginning but grows into the uterine cavity. In our series, one case was interstitia1, 9 were of the isthmic type and 28 were cases of tuba1 abortions or tuba1 moIes. The location of the ectopic pregnancies in our series proves that the ampuIIar type is by far the most common, the isthmic

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type Iess frequent rather uncommon.

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and the interstitial

type

PATHOLOGY

The ovum burrows its way into the structure to which it is Iater to become attached, finaIIy forming a capsuIe consisting of chorionic ceIIs; this is caIIed the pseudo-decidua reff exa. PeritoneaI involvement becomes IikeIy when the syncytia1 ceIIs nearIy reach the serous coat of the tube, after penetrating the venous radicaIs and riddIing the muscIe Iayer, with resulting hemorrhage into the decidua. This in turn tends to unseat the ovum and overdistends the tube, and finaIIy.ruptures the pseudo-decidua reflexa, causmg the pain and bIeeding. The bIeeding partI)- dislodges the ovum and causes the cIinica1 symptom of coIicky pain. This unrest causes uterine with sIight bIeeding from contractures, the endometrium. The blood mixes with the secretion from the hypertrophied utricuIar gIands and produces the characteristic bIoody discharge which does not cIot. The tuba1 pregnancy then terminates in the foIIowing ways: (I) ovum dies and is absorbed; (2) the formation of a tubal moIe; (3) tuba1 abortion or tuba1 rupture. The tuba1 abortion may be threatened, inevitabIe or compIete. The beginning of the abortion, as described, is the breaking through the capsuIe of the o\-urn, or the pseudo-decidua reflexa. This must be an intratuba1 rupture and is not to be confused with extratubuIar rupture. However, the mechanics are about the same, and when the Iatter occurs bIeeding takes place into the peritonea1 cavity whiIe in the former it takes pIace into the lumen of the tube. The separation of the ovum may be compIete or partia1, when the products remain in situ. The hemorrhage then may cease but recur periodicaIIy. If the separation is partia1 and bIood surrounds the capsuIe, a moIe wiI1 be the resuIt. Perforation is most Iikely to take place in the isthmus or interstitial portion be-

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cause the Iumen is so narrow. In this type, perforation usuaIIy takes pIace into the peritonea1 cavity. Here the hemorrhage may be marked and operation is indicated at once. TREATMENT

AI1 writers agree that surgery is the onIy method of treatment in extrauterine pregnancy. In the tragic cases, those admitted in severe shock, the exact time of surgica1 interference is a mooted question. There are two schooIs: one, those who beIieve that surgica1 interference is indicated at once, no matter how severe the shock may be or whether the patient has reacted to the interna bIeeding. Their theory is that for recovery, the bleeding vesseIs must be ligated and that in many cases the bIeeding wiI1 not cease, nor wiI1 the patient survive, unti1 operative measures are used. Such weII-known men as Schuman, Hirst, Watkins and others support this method. The other schooI, supported by the Iate John 0. PoIak, beIieves that surgery is indicated in these tragic cases but not unti1 the hemorrhage is partIy controIIed by cIotting, and the patient has been aIIowed to react, which, he states, aIways occurs, and unti1 the bIood pressure, which may have been imperceptibIe, has become eIevated to a systoIic reading of go or above. After the primary reaction, surgery is indicated, the immediate treatment in this type of case being measures to combat shock, such as heat, TrendeIenburg position and morphine. Transfusions are not indicated because the bIeeding point has not been surgicaIIy controIIed, the become disIodged from the cIot may bIeeding vesse1 and additiona hemorrhage may foIIow. During the series reported, the Iatter method of treatment has been foIIowed and our resuIts, as were Dr. PoIak’s, have been most gratifying. However, series reported by men who foIIow the first method of treatment show resuIts

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which are equaIIy remarkabIe. We certainIy do not condemn the method. Three of our patients were auto-transfused. AI1 of these did we11 postoperatively and none showed any detrimenta reactions from the transfusions. In one case 600 c.c., in the second 800 C.C. and in the third 1500 C.C. were given. AI1 the cases were grave at the. time of operation and we beIieve that in these cases a fata end was avoided by our method of auto-transfusion. In many instances vaIuabIe time is Iost in obtaining, typing and cross-matching a donor. We fuIIy reaIize that this bIood may be contaminated and that bIood stream infections may result, but we beIieve that this occurs infrequentIy. Our apparatus for auto-transfusion is very simpIe; nameIy, a steriIe suction jar, tube and suction tip. A very smaI1 incision is made through the peritoneum, the tip inserted into the free bIood and for every 500 C.C. of bIood removed, 25 C.C. of a 2 per cent sodium citrate soIution are added. The bIood is then fiItered through many Iayers of gauze and re-injected into the veins of the arm by the gravity method. Other methods can be used, as the ScanneII apparatus or removing the bIood by a IadIe, but the foregoing is the quickest, the easiest and the most reIiabIe. Ricei, from the Iiterature, coIIected 282 cases which had been transfused with 2 of these patients were onIy 6 deaths; moribund at operation, giving a mortaIity rate of 2.2 per cent. CoIpotomy is resorted to, but onIy in the most diffIcuIt case, and is not our routine. It is not aIways sure that bIood wiI1 be aspirated, and there exist other dangers which might be foIIowed by serious consequences. We may have intraperitonea1 bIeeding from any other cause; for instance, a perforated uIcer may present nearIy the same symptoms. We advocate coIpotomy rather than cuI-de-sac punctures with needIes. DiIatation and curettage are occasionaIIy resorted to, but onIy to differentiate

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between the threatened abortion and the ectopic in the doubtfu1 case. The blood which is found free in the peritonea1 cavity is aIIowed to remain, the cIots are removed. It is not our practice to fiI1 the peritonea1 cavity, before cIosure, with norma saIine soIution. Transfusions, intravenous gIucose, cIysis of saIt soIution, are aIways heId in readiness and are given as the occasion may arIse. Our surgery is aIways done through the abdomina1 route. If possible, onIy the faIIopian tube containing the rupture is removed, aIIowing the ovary to remain in situ, unIess it is impossibIe or inadvisable because of the patient’s condition. In a few of our cases, conservative measures removing onIy the were used, diseased part of the tube at the time. We do not recommend this, but in none of these cases have ectopics recurred. The opposite adnexa is never’ interfered with if no pathoIogica1 condition is discovered. In the series reported by Hirst for a five-J-ear period, 7 of his 167 patients had ectoplcs occur in the other tube, 30 had since become pregnant and deIivered normall)-. SUMMARY I. Previous peIvic disease is an important etioIogica1 factor. 2. HormonaI disturbances present a new thought as to the etioIogy of ectopics. 3. Most of our patients with extrauterine pregnancy were between the ages of twenty and thirty-three. 1. The history of previous steriIity pIays a minor role. 3. The two most common symptoms are abdomina1 pain and irreguIar bIeeding. 6. The most common vagina1 finding is tenderness on motion of the cervix.

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7. The most important laboratory method is the sedimentation time; and this shouId never be omitted in the doubtfu1 case. 8. The Aschheim-Zondek test is vaIuabIe and shouId be used when indicated. 9. The ampuIIar type is the most frequent. 10. Surgery is the onIy method of treatment. I I. Auto-transfusions are indicated and shouId be empIoyed in a11 cases of a serious nature. 12. OnIy the disease faIIopian tube shouId be removed. 13. CoIpotomy shouId be resorted to 0nIy 0ccasionaIIy. 14. Diagnosis in the unruptured case is aImost impossibIe. 15. A compIete and accurate history is most vaIuabIe in arriving at a correct and earIy diagnosis. REFERENCES

Obstetrics and GynecoIogy. PhiIa., Saunders, 1933. Obstetrical and Gynecological Monographs. N. Y., AppIeton, 1924. GIBSON, R. B. EctoDic Dreenancv and its treatment. J. Oklahoma M. &A.,‘ppr 355-<60 (Oct. 26) 1933. RHODES and COLLINS. CIinicaI study and notes on treatment and value of auto-transfusions. WeStern J. &kg., 40: 252-257 (May) 1932. 5. BAENO. Report of 174 cases of ectopic pregnancy. J. Philippine Island ,zI. A., 12: &&p~ (Oc;.) CURTIS.

1933. 6. DUMPHY and FALLON. Diagnosis with note on signiticance of jaundice. NW England J. M., 205: 540-542 (Skpt.) ‘93’. a factor incidence of tuba1 7. VAN ELTEN. SaIDineitis. _ _ pregnancy. Am. J. Obst. (I” Gynec., 22: 643-646 (Oct.) ‘931. 114ed. J. Australia, 2: 8. DAWSON. Auto-transfusions. 49-rjo (JuIy) 1930. 9. URDAN. CIinicaI study, 474 cases of ectopic. Am. J. Obst. c+?Gynec., io: 355-372 (Sept.) 1-930. folIowing use of Dessarv. IO. PoTrxR. CompIications AM. J. SURF., IO: 143-148, 1930. I d II. LAVEI.LE. Diagnosis of ectopic gestation, 4 I o cases. Am. J. Obst. @ Gynec., 18: 379-392, 1929. 12. POLAK. Am. J. Obst. C+Gynec., 2: ,925. 13. FARR~R. Am. J. Obst. C* Gpec., 70: 733. TOE<).