Abdominal Pregnancy

ABDOl\HNAL PREGNANCY FREDERICK

P. ZusPAN, M.D.,* EDWARD J. QVILLIGAN, M.D., M. RosENBLUM, M.D., CLEVELAND, OHIO

AND JEROLD

(From the Department of Obstetrics and Gynecology Western Resert'e Unit,ersity and UnitJersity Hospitals) 7

abdominal pregnancy occurs infrequently, thr incidence has ALTHOUGH increased since the advent of antibiotics. This increase is generally attributed to the fact that the modern treatment of pelvic inflammatory disease renders fewer women infertile but leaves more womrn with some form of tubal impediment. 1 • 2 Most authors feel that abdominal pregnancies are the result of tubal abortion, either partial or complete, with reimplantation outside the tube. 2 • 3 ' 4 The incidence of this gestational catastrophe varies dirrctly with the incidencr of pelvic inflammatory disease. 1 • 2 • 5 • n Material

There were 3 abdominal pregnancies recorded in this Hospital from 1927 to 1951. The 11 cases reported here occurred during the years 1951 through April, 1956. The ratio of abdominal pregnancies to total deliveries on the clinic service was 1 :782. No abdominal pregnancies occurred on the private service during this period. Therefore the ratio of abdominal pregnancies to total patients delivered would be 1:1,955. All abdominal pregnancies except one occurred in Negro patients and this would parallel our clinic incidence of Negro and white patients. Barrett,' quoting the incidence of abdominal pregnancies to total deliveries, gives the high figure of 1 :286. The range in occurrence of abdominal pregnancies reported is from 1 :286 to 1 :15,000. 1 • 5 • 7 • 8 'l'he average age of this group of patients was 30 years. Six of them were primigravidas. The distribution according to period of gestation at the time of diagnosis was: 3 in the first trimester, 3 in the second trimester, and 5 in the third trimester. The diagnosis was made preoperatively in 8 out of 11 cases. These data are summarized in Table I. Diagnosis Most cases of abdominal pregnancy do not present a classical picture. Some of the signs and symptoms thought to be helpful in the diagnosis 3 • 5 • 8 are: ( 1) an abdominal crisis early in pregnancy; (2) palpation of the superficial fetal small parts; (3) unusually loud fetal heart tones; ( 4) inability to palpate the round ligaments and absence of Braxton Hicks contractions; ( 5) "false labor"; ( 6) persisting abdominal pain or tenderness; ( 7) definite displacement of the cervix; (8) high position or transverse lie of the fetus; (9) signs of fetal death; ( 10) identification of an extrauterine mass. Two ancillary aids helpful in making the diagnosis are the oxytocic extract test and hysterosalpingograms. 9 • 10 Some of the above listed findings, if present, *Present address:

McDowell Memorial Hospital, McDowell, Ky.

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PHYSICAL FINDINGS

HISTORY, PHYSICAL FllNDINGS, AND LABORATORY WORK ON PATIENTS STUDIED

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Voiume 74 Number 2

261

PREG:t{A:l{CY

could serve to establish the diagnosis of an abdominal pregnancy, but all too often not enough of them are present, or the proper significance is not attached to them. The length of gestation also affects the probability of the presence of certain signs or symptoms. Obviously, however, the correct diagnosis of an abdominal pregnancy rests chiefly on a high index of suspicion on the part of the clinician. As a general statement, any pregnant patient whose clinical course does not conform to a ''normal'' pattern or who has unexplained abdominal panr wnn or wnnom; recar oem;n snouta oe suspectea or nav1ng an aooormnar pregnancy. The symptoms most frequently encountered in these 11 patients were (Table I): (1) lower abdominal pain; (2) cessation of fetal motion; (3) vaginal bleeding; ( 4) vomiting. In the physical examination the following findings were helpful in the cases ~-

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(2) a small uterus or one not compatible with the length of gestation; (3) absent fetal heart tones. Anemia of less than 9.5 Gm. of hemoglobin was present in more than one half of the cases. Three patients developed severe hypotension either during or immediately after an examination under anesthesia. One of the easiest diagnostic tests available to differentiate intra-uterine from extrauterine gestations is the oxytocic extract test. Colvin and McCord 10 first proposed this as a diagnostic test in 1934, using pituitary extract subcutaneously. Since the advent of Pitocin the test has been altered and can now be done with more safety as an intravenous infusion. A tokodynamometer makes this a relatively easy way of determining whether the patient is having uterine contractions. 9 We have seen good uterine contractile responses with intravenous Pitocin in patients who were only fourteen to sixteen weeks pregnant. The intravenous Pitocin did not cause abortions in any of the normally pregnant patients. This test was utilized on 3 patients with abdominal pregnancy and 6 suspected cases of abdominal pregnancy. Uterine contractions were palpated in all intrauterine gestations and none in abdominal gestations. Management

There is some disagreement in the literature concerning the management of the patient with abdominal pregnancy. If fetal death has occurred, some authors 3 • 11 prefer to wait from seven days to eight weeks until the placental circulation decreases, minimizing the danger of hemorrhage at the time of operation. Others5 • 7 • 8 • 12 feel that such delay results only in an increased susceptibility to infection with a resultant increase in the maternal morbidity and mortality. In these patients, when the diagnosis of abdominal pregnancy was established, laparotomy was immediately performed. Jeopardy to the patient's life comes from two causes-hemorrhage and infection. If operation is performed as soon as the diagnosis is made, the incidence of intra-abdominal infection is lowered. It is known that approximately one third to one half of extrauterine fetuses will present some type of major or minor deformity. 13 • 14 It seems hardly logical to subject a patient to the hazards of procrastination only to succeed eventually in delivering a deformed child. The management of the placenta does not begin after the fetus has been extracted but begins in the preoperative state. If an abdominal pregnancy has been suspected, adequate blood should be available. If, however, the diagnosis is not made until laparotomy, it is wise to wait until at least 4 units of blood are available to handle the immediate problem of delivery of the placenta. The vascularity of the placenta varies with viability and the location. 1 • 3 • 5 • 14 It

262

ZUSPAN, QUILLIGAN, AND ROSENBLUM

Am. ]. Obst. & Gynec August, 1957

is impossible to make a dogmatic statement concerning the management of the placenta. Each case must be taken individually and managed in relation to the problems at hand after the fetus has been extracted. This decision is important and should be decisive~either an attempt to remove the placenta is made or it is loft in situ. The decision has to be influenced by the location of the placenta and the condition of the patient, together with the availability of whole blood. It is unwise to attempt too much manipulation of the placenta unless it has been definitely decided to remove it. If it is to be removed, one of tht• best means of controlling hemorrhage is by pressure either at the bleeding site or directly on the aorta and other large vessels in the area. Burch'" used an aortic clamp to obtain adequate hemostasis. The same end result can be obtained if an assistant uses digital compression of the aorta against the vertebral column. Such aortic eompression will be of value only if the parasitic blood supply of the placenta arises below the level of the renal vessels. After removal of the plaeenta bleeding from the vascular bed ran be controlled by hot laparotomy taprs and by Gelfoam. 'L'ABLE

II.

MANAGEMENT AND SUBSEQUENT COURSE OF' PATIENTS STUDIED

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PREOPERATIVE DIAGNOSIS

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PATIENT

pregnancy Toxemia with uncontrolled hypertension Ruptured uterus Intrauterine pregnancy Abdominal pregnancy

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Ectopic pregnancy Abdominal pregnancy Abdominal pregnancy Abdominal

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OPERATION

-}.'etus-·removed Fetus and placenta removed. Panhysterectomy Fetus removed Fetus and placenta removed Fetus removed

Fetus and placenta removed Fetus and placenta removed. Panhysterectomy Placenta and fetus removed Fetus and placenta removed Fetus and pla· centa removed Fetus and pla~enta removed

BLOOD REPLACEMENT ( C.C.) I

4,000

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SUBSEQUENT SURGERY

MORBIDITY IN DAYS

3,000

Multiple colpotomies None

None 1.000

None None

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2,500

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None

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500

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500

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2,500

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None None

60

If the placenta is not removed one is faced with the delayed effects of a foreign body in the abdominal eavity. Some authors 2 • 8 ' 16 • 17 advocate that nothing be done with the placenta, on the assumption that spontaneous resorption will take plaee. Other authors 5 • s, 18 - 22 report in increased morbidity when the placenta is left in situ. The latter has been our experience (Table II). Two of the patients from whom the placenta was not removed during the original operation required prolonged hospital stays and additional operations. Each of these patients had a protraeted septic course. The average stay of the patient whose placenta was left in situ was 51 days, in contrast to 13 days for those from whom the placentas were removed (Table III). No maternal death occurred in this whole group of patients and only one living child was delivered.

_A._BD01vii:NAL

Volume i4 Number 2

TABLE III.

263

PREGN"A:t~CY

SUMMARY OF 11 ABDOMINAL PREGNANCIES

Average age Parity Primigravidas Multigravidas Race Negro White Length of gestation First trimester Second trimester Third trimester Preoperative diagnosis Correct Incorrect Averagr> hPmoglobin Average blood replacement Postoperative hospital stay in days Placenta in PlacPnta out

30 years

6

5 10

1

3 3

5 8 3 9.2 Gm. 1,863 c.c.

Range 5.3 to 12.7 Gm. Range 0 to 5,000 c.c.

51 13

Summary 1. Eleven abdominal pregnancies are reported. 2. A high index of suspicion resulted in the correct preoperative diagnosis in 8 of the cases. 3. The most common findings were abdominal pain, cessation of fetal motion, vomiting, anterior displacement of the cervix, and unexplained anemia. 4. Once the diagnosis was established, immediate laparotomy ·was the treatment of choice in this series. Adequate blood replacement prior to operation and the availability of at least 4 units of whole blood at the time of surgery are mandatory. 5. Management of the placenta must be individualized. In this group of patients there was a marked decrease in morbidity if the placenta was removed during the initial operation. 6. No maternal deaths occurred and only one living child was delivered.

References 1. 2. 3. 4. 5. 6. 7.

8. 9. 10.

11. 12. 13. 14. 15. 16. 17. 18. 19. ~0.

21. 22.

Barrett, M. E.: Am. J. Obst. & Gynec. 64: 1061, 1952. Te Linde, R.: Operative Gynecology, ed. 2, Philadelphia, 1953, J. B. Lippincott Company. Horner, H., and Harrison, H. E.: U. S. Armed Forces M. J. 6: 181, 1955. Greenhill, J. P.: Principles and Practice of Obstetrics, originally by Joseph B. DeLee, ed. 10, Philadelphia, 1951, W. B. Saunders Company. Beacham, W. D., and Beacham, D. W.: Obst. & Gynec. Surv. 1: 777, 1946. Douglass, L. H., and Kohn, S. G.: West Virginia M. J. 43: 307, 1947. Eastman, N. J.: Williams Obstetrics, ed. 10, New York, 1950, Appleton-Century-Crofts, Inc., p. 520. Cross, J. B., Lester, W. M., and McCain, J. R.: AM. J. OBST. & GYNEC. 62: 303, 1951. Chessin, H., and Zussman, L.: Obst. & Gynec. 4: 440, 1954. Colvin, E. D., and MeCord, J. R.: AM. J. 0BST. & GYNEC. 27: 421, 1934. Lull, C. B.: AM. J. 0BST. & GYNEC. 40: 194, 1940. Ware, H. H., Jr.: AM. J. OBST. & GYNEC. 55: 561, 1948. Suter, M., and Wichser, C.: AM. J OBST. & GYNEC. 55: 489, 1948. Hellman, A. M., and Simon, H. J.: Am. J. Surg. 29: 403, 1935. Burch, B. H., Traphagen, D. W., and Folkman, M. J.: Surgery 34: 672, 1953. Nethery, R. A.: AM. J. OBST. & GYNEC. 69: 435, 1955. Beck, A. C.: J. A.M. A. 73: 962, 1919. Laycock, H. T.: Brit. M. J. 2: 688, 1954. Branscomb, L.: AM. J. 0BST. & GYNEC. 54: 874, 1947. Mason, L. W.: AM. J. 0BST. & GYNEC. 39: 756, 1940. Jarrett, J. C.: Ohio M ..J. 48: 219, 1952. Hazlett, W. H.: Obst. & Gynec. 1: 313, 1953.