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Bilateral tubal pregnancy
Case Reports BILATERAL
TUBAL
PREGNANCY PHILIP
(From the of Medicine
Department of Loyola
of Obstetrics University)
and
Gynecology,
C.
WILLIAMS,
Provident
M.D.,
Hospital,
CHICAGO,
and
Stritch
ILL. School
B
ILATERAL tubal pregnancies, of the same age or of different ages, are considered the rarest form of double ovum twin pregnancies. Therefore an authentic case which meets the criteria as enumerated by Fishbackl merits reporting. Fishback in 1939 pointed out that the embryo or chorionic villi must be present bilaterally in order to establish a diagnosis of bilateral tubal pregnancy. The incidence of bilateral ectopic gestation at the Cook County Hospital, as reported by Abrams and Kante? in 1948, was l&580 ectopic pregnancies. Stewart,3 in 1950, in his report of a case, reviewed the world literature and reported the incidence to be 1:725 ectopic pregnancies. In February, 1952, Hofmeister and Hultman4 in their analysis of 83 cases of ectopic pregnancy at the Milwaukee Hospital listed a case of bilateral tubal pregnancy. In August, 1952, Evans and Goyanes5 reported their case as the one hundred and fortysecond authentic instance of bilateral tubal pregnancy. Case Report V.
A., a 27.year-old Negro woman, para iii, gravida iii, was admitted to the Gynecological Service of Provident Hospital on Feb. 7, 1954, complaining of generalized lower Her last normal abdominal pain and irregular vaginal bleeding for the preceding month. menstrual period was on Dec. 7, 1953. On Jan. 9, 1954, she started a regular menstrual period of 4 days’ duration. Within several days she began to bleed irregularly and to have lower abdominal pain which was more marked on the right side. The pain and bleeding were increased on urination or defecation. The past history disclosed the presence of pelvic inflammatory disease. The youngest child was 6 years of age. The physical examination showed a well-developed, well-nourished woman in slight distress. The temperature, pulse, and respiration were normal. The blood pressure was 110/70. The abdomen was flat, soft, and nontender. On pelvic examination the cervix pointed down 1132
Volume
Number
BILATERAL
74
5
TUBAL
1133
PREGNANCY
and forward, and was freely movable with slight tenderness. The corpus was in first degree retroversion, firm, a little enlarged, with slight tenderness on movement. The right adnexa were thickened and tender. The left adnexa displayed no masses or tenderness. On speculum
Fig.
1.-A,
Photograph
of right
tube
showing
rupture.
B,
Figure
shows
typical
chorionic
villi.
Am. J. Obst. & Gynec.
WILLIAMS
Nownber.
examination the cervix was eroded and the os was patulous. were entertained: (1) possible right tubal pregnancy, (2) ease, (3) incomplete abortion.
The following subsiding pelvic
195:
clinical diagnoses inflammatory dis-
Laboratory tests showed the following: hemoglobin, 13.3 Gm. per 100 cc.; hematocrit, 43; white cell count, 14,200 with a differential of 80 per cent polymorphonuclear cells, 14 per cent lymphocytes, 2 per cent monocytes, 2 per cent eosinophils, 2 per cent basophils. The sedimentation rate was 42 mm. per hour. Urinalysis was negative except that microscopic examination showed 10 to 12 white blood cells per high-power field. The sickling test was negative. A.
R.
Fig.
Z.-A,
Photograph
of left
tube
showing
rupture.
B,
Figure
shows
typical
chorionic
villi.
An Aschheim-Zondek test was ordered and the patient was pIaced on antibiotic therapy. On Feb. 10, 1954, the Aschheim-Zondek test was reported positive. It was felt that the patient should have a vaginal examination under anesthesia, a curettage, a posterior colpotomy, or exploratory laparotomy. On examination the cervix was found to be patulous and readily admitted a small Hegar dilator. A moderate amount of decidual tissue was obtained on curettage. Colpocentesis was negative. The clinical impression at this time was that this was an incomplete abortion. The patient became asymptomatic and was discharged on the fourth postoperative day. The patient was readmitted to the hospital one week later, on Feb. 17, 1954, because she had experienced an acute pain on the right side and had gone to the bathroom and had fainted. On admission the blood pressure was 90/60, pulse 120. She was immediately taken to the operating room. A pelvic examination was made and a markedly tender right adnexal mass
Volume Number
BILATERAL
71 5
A diagnosis was found. laparotomy was performed pregnancy was found. was performed. Before was made and disclosed pingectomy was done. recovery was uneventful Pathological
Report
TUBAL
1135
PREGNANCY
of
ruptured right tubal pregnancy was made and an immediate At operation a ruptured right tubal under general anesthesia. Since the right ovary was involved, a right salpingo-oophorectomy the abdomen was closed, a routine examination of the opposite tube a hemorrhagic mass in the middle third of the left tube. A left salThe patient received 1,000 C.C. of blood during the operation. Her and she was discharged on the ninth postoperative day. (by
Dr.
N. I. Kohut)
.--
Right tube, right ovary, and fetzcs: Gross: The specimen consisted of a fetus which was 5 cm. in length, a torn ovary attached to a tube which was coiled so that it was 5 cm. in length and 3 cm. in width. There was a tear in the wall of the tube which contained blood clot and a soft gray friable placenta-like tissue. The ovary contained a large hemorrhagic corpus luteum, and the entire ovarian mass measured about 4 by 3 by 1 em. (Fig. 1, d). Microscopic: Portions of a corpus luteum of pregnancy A portion of also showed other developing Graafian follicles. well-preserved immature chorionic villi covered by two distinct wall was edematous and had many dilated blood vessels, and at invasion (Fig. 1, 23).
were present in the ovary which Fallopian tube contained many layers of epithelium. The tube some levels showed trophoblastic
Left tube: Gross: The specimen was a single Fallopian tube which measured 11 cm. in length. It had a diameter of 0.5 cm. for a distance of 3 em., dilating to 1.5 cm. for a variable distance of 3 cm., and then 0.6 cm. for the next 3 cm. The serosal surface was gray and glistening and the fimbriated end was hyperemic with fibrous adhesions. Contained within the tube was a soft grayish-green tissue lying free except at the portion where the tube was most dilated, and here it was an adherent mass, dark red and yellowish tan, measuring about 1.5 cm. in greatest diameter. A section was taken of the tubal wall at the point of the adherent mass (Fig. 2, a). Microscopic: This tubal tissue contained a poorly preserved, necrotic portion of placental tissue with ghosts of chorionic villi remaining, surrounded by organized blood clots and many pigment-filled macrophages. Portions of Fallopian tube wall were infiltrated by many inflammatory cells and partially surrounded the organized clot and old tissue (Fig. 2, B). Diagnosis: Fallopian tube.
Right
tube--pregnancy
of
Fallopian
tube;
left
tube-old
pregnancy
of
Comment The pathological findings described fulfill Fishback’s criteria. Since there are no characteristic signs or symptoms peculiar to this entity other than those referable to a unilateral ectopic gestation, this diagnosis is usually made at the time of operation. This case also demonstrates the importance of examining both adnexa in a laparotomy for an ectopie pregnancy. Summary 1. A case of bilateral tubal pregnancy is presented. 2. The diagnosis of bilateral tubal pregnancy is made at operation. 3. Both adnexa should be thoroughly examined when a laparotomy performed for unilateral tubal pregnancy or other adnexal pathology. References 1. 2. 3. 4. 5.
Fishback, Hamilton R.: AM. J. OBST.& GYNEC.~~: 1035,1939. Abrams, R. A., and Kanter, A. E.: AI&J. OBST.& GYNEC. 56: 1198,1948. Stewart, H. L.: West. J. Surg. 58: 648, 1950. Hofmeister, F. J., and Hultman, C. A.: Wisconsin M. J. 51: 166, 1952. Evans, G. E., and Goyanes, E.: AM-J. OBST.& GYNEG.~~: 444,1952.
is
TUBAL
PREGNANCY PHILIP
(From the of Medicine
Department of Loyola
of Obstetrics University)
and
Gynecology,
C.
WILLIAMS,
Provident
M.D.,
Hospital,
CHICAGO,
and
Stritch
ILL. School
B
ILATERAL tubal pregnancies, of the same age or of different ages, are considered the rarest form of double ovum twin pregnancies. Therefore an authentic case which meets the criteria as enumerated by Fishbackl merits reporting. Fishback in 1939 pointed out that the embryo or chorionic villi must be present bilaterally in order to establish a diagnosis of bilateral tubal pregnancy. The incidence of bilateral ectopic gestation at the Cook County Hospital, as reported by Abrams and Kante? in 1948, was l&580 ectopic pregnancies. Stewart,3 in 1950, in his report of a case, reviewed the world literature and reported the incidence to be 1:725 ectopic pregnancies. In February, 1952, Hofmeister and Hultman4 in their analysis of 83 cases of ectopic pregnancy at the Milwaukee Hospital listed a case of bilateral tubal pregnancy. In August, 1952, Evans and Goyanes5 reported their case as the one hundred and fortysecond authentic instance of bilateral tubal pregnancy. Case Report V.
A., a 27.year-old Negro woman, para iii, gravida iii, was admitted to the Gynecological Service of Provident Hospital on Feb. 7, 1954, complaining of generalized lower Her last normal abdominal pain and irregular vaginal bleeding for the preceding month. menstrual period was on Dec. 7, 1953. On Jan. 9, 1954, she started a regular menstrual period of 4 days’ duration. Within several days she began to bleed irregularly and to have lower abdominal pain which was more marked on the right side. The pain and bleeding were increased on urination or defecation. The past history disclosed the presence of pelvic inflammatory disease. The youngest child was 6 years of age. The physical examination showed a well-developed, well-nourished woman in slight distress. The temperature, pulse, and respiration were normal. The blood pressure was 110/70. The abdomen was flat, soft, and nontender. On pelvic examination the cervix pointed down 1132
Volume
Number
BILATERAL
74
5
TUBAL
1133
PREGNANCY
and forward, and was freely movable with slight tenderness. The corpus was in first degree retroversion, firm, a little enlarged, with slight tenderness on movement. The right adnexa were thickened and tender. The left adnexa displayed no masses or tenderness. On speculum
Fig.
1.-A,
Photograph
of right
tube
showing
rupture.
B,
Figure
shows
typical
chorionic
villi.
Am. J. Obst. & Gynec.
WILLIAMS
Nownber.
examination the cervix was eroded and the os was patulous. were entertained: (1) possible right tubal pregnancy, (2) ease, (3) incomplete abortion.
The following subsiding pelvic
195:
clinical diagnoses inflammatory dis-
Laboratory tests showed the following: hemoglobin, 13.3 Gm. per 100 cc.; hematocrit, 43; white cell count, 14,200 with a differential of 80 per cent polymorphonuclear cells, 14 per cent lymphocytes, 2 per cent monocytes, 2 per cent eosinophils, 2 per cent basophils. The sedimentation rate was 42 mm. per hour. Urinalysis was negative except that microscopic examination showed 10 to 12 white blood cells per high-power field. The sickling test was negative. A.
R.
Fig.
Z.-A,
Photograph
of left
tube
showing
rupture.
B,
Figure
shows
typical
chorionic
villi.
An Aschheim-Zondek test was ordered and the patient was pIaced on antibiotic therapy. On Feb. 10, 1954, the Aschheim-Zondek test was reported positive. It was felt that the patient should have a vaginal examination under anesthesia, a curettage, a posterior colpotomy, or exploratory laparotomy. On examination the cervix was found to be patulous and readily admitted a small Hegar dilator. A moderate amount of decidual tissue was obtained on curettage. Colpocentesis was negative. The clinical impression at this time was that this was an incomplete abortion. The patient became asymptomatic and was discharged on the fourth postoperative day. The patient was readmitted to the hospital one week later, on Feb. 17, 1954, because she had experienced an acute pain on the right side and had gone to the bathroom and had fainted. On admission the blood pressure was 90/60, pulse 120. She was immediately taken to the operating room. A pelvic examination was made and a markedly tender right adnexal mass
Volume Number
BILATERAL
71 5
A diagnosis was found. laparotomy was performed pregnancy was found. was performed. Before was made and disclosed pingectomy was done. recovery was uneventful Pathological
Report
TUBAL
1135
PREGNANCY
of
ruptured right tubal pregnancy was made and an immediate At operation a ruptured right tubal under general anesthesia. Since the right ovary was involved, a right salpingo-oophorectomy the abdomen was closed, a routine examination of the opposite tube a hemorrhagic mass in the middle third of the left tube. A left salThe patient received 1,000 C.C. of blood during the operation. Her and she was discharged on the ninth postoperative day. (by
Dr.
N. I. Kohut)
.--
Right tube, right ovary, and fetzcs: Gross: The specimen consisted of a fetus which was 5 cm. in length, a torn ovary attached to a tube which was coiled so that it was 5 cm. in length and 3 cm. in width. There was a tear in the wall of the tube which contained blood clot and a soft gray friable placenta-like tissue. The ovary contained a large hemorrhagic corpus luteum, and the entire ovarian mass measured about 4 by 3 by 1 em. (Fig. 1, d). Microscopic: Portions of a corpus luteum of pregnancy A portion of also showed other developing Graafian follicles. well-preserved immature chorionic villi covered by two distinct wall was edematous and had many dilated blood vessels, and at invasion (Fig. 1, 23).
were present in the ovary which Fallopian tube contained many layers of epithelium. The tube some levels showed trophoblastic
Left tube: Gross: The specimen was a single Fallopian tube which measured 11 cm. in length. It had a diameter of 0.5 cm. for a distance of 3 em., dilating to 1.5 cm. for a variable distance of 3 cm., and then 0.6 cm. for the next 3 cm. The serosal surface was gray and glistening and the fimbriated end was hyperemic with fibrous adhesions. Contained within the tube was a soft grayish-green tissue lying free except at the portion where the tube was most dilated, and here it was an adherent mass, dark red and yellowish tan, measuring about 1.5 cm. in greatest diameter. A section was taken of the tubal wall at the point of the adherent mass (Fig. 2, a). Microscopic: This tubal tissue contained a poorly preserved, necrotic portion of placental tissue with ghosts of chorionic villi remaining, surrounded by organized blood clots and many pigment-filled macrophages. Portions of Fallopian tube wall were infiltrated by many inflammatory cells and partially surrounded the organized clot and old tissue (Fig. 2, B). Diagnosis: Fallopian tube.
Right
tube--pregnancy
of
Fallopian
tube;
left
tube-old
pregnancy
of
Comment The pathological findings described fulfill Fishback’s criteria. Since there are no characteristic signs or symptoms peculiar to this entity other than those referable to a unilateral ectopic gestation, this diagnosis is usually made at the time of operation. This case also demonstrates the importance of examining both adnexa in a laparotomy for an ectopie pregnancy. Summary 1. A case of bilateral tubal pregnancy is presented. 2. The diagnosis of bilateral tubal pregnancy is made at operation. 3. Both adnexa should be thoroughly examined when a laparotomy performed for unilateral tubal pregnancy or other adnexal pathology. References 1. 2. 3. 4. 5.
Fishback, Hamilton R.: AM. J. OBST.& GYNEC.~~: 1035,1939. Abrams, R. A., and Kanter, A. E.: AI&J. OBST.& GYNEC. 56: 1198,1948. Stewart, H. L.: West. J. Surg. 58: 648, 1950. Hofmeister, F. J., and Hultman, C. A.: Wisconsin M. J. 51: 166, 1952. Evans, G. E., and Goyanes, E.: AM-J. OBST.& GYNEG.~~: 444,1952.
is