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Diagnostic Errors in Extra-Uterine Pregnancy
Medical Clinics of North America January, 1938. Chicago Number
CLINIC OF DR. N. SPROAT HEANEY PRESBYTERIAN HOSPITAL
DIAGNOSTIC ERRORS IN EXTRA-UTERINE PREGNANCY
I HAVE a very interesting case to present this morning. This patient is a young single woman sent to us for the removal of her appendix because of right-sided pain associated with a leukocytosis pf 18,000. This young woman of twenty-six has always been perfectly well and sturdy until the onset of the present difficulty yesterday early. While at stool after breakfast she had a rather sharp pain in the right side, transitory in nature, which, though short in duration, left her exhausted. The bowel movement was formed and was accompanied by no unusual amount of gas. The patient had a formed bowel movement again this morning so we can rule out bowel colic as the cause of her pain rather certainly. At noon yesterday after eating heartily she had another seizure of pain of similar character somewhat sharper but also short in duration. Early this morning a third attack of pain occurred still more intense and at that time she called a physician who found her tender over the region of the appendix. He made a leukocyte count and found it 18,000 while her temperature and pulse were normal. Now, this patient is before us and not one word has been said by her attending physician nor by the intern, who took her history, about her menstrual periods. How many errors in medicine are attributable to that lapse. I want to tell you that you will be wise to take a menstrual history on every woman you are called upon to treat. It may be thought that a brain tumor is present and is producing vomiting until a menstrual history with subsequent examination shows that the vomiting is due to an ordinary common everyday pregnancy. 21 3
N. SPROAT HEANEY
You may be a skin man treating a case of baffling urticaria until a menstrual history shows that the patient is pregnant and the urticaria is toxic in origin. When we question this patient about her menses she states that she has been always regular every twenty-eight days and that her last menstrual period was ten days ago and on time. If you want to avoid frequent and important errors in gynecologic diagnosis you must not take a statement to the effect that the last period was on time and normal in every way, without a bit of doubt. Every woman will stand a little cross examination on this point. First of all, if a woman really menstruates every twenty-eight days on the dot then she must necessarily begin menstruating each time on the same day of the week. Occasionally a woman· is that regular, but most are not. This woman says that she does not always begin to menstruate on the same day of the week so immediately we know that her last menstrual period's regularity is questionable; it may have been a few days late without attracting her attention. She states that the period was normal but when we examine into details she says that while she normally menstruates always for four or five days and uses 10 to 12 pads that this time she "menstruated" very scantily for three days then stopped entirely for a day or two and then began spotting, and that this spotting has continued until now. Gentlemen, this is a very suspicious symptom in a woman complaining of "appendicitis." When I asked this patient if there were any chance of her being pregnant she was indignant at the suggestion. This proves nothing, however. If she had said there was, it would have been contributing testimony; her denial means nothing. Last week I saw a girl close to term where the fetal parts could be mapped out and where you could hear the unmistakable fetal heart and could see the baby lunge about and yet she insisted that I was in error. So we will not allow the history in this regard to influence us. So we will proceed to our examination to prove that this patient who has been regular all her life, menstruating each month for five days and each time freely, and for a like amount each month, but who ten days ago had an abnormal period, is not pregnant. My belief is that she is, for any woman who has a scanty "period" and then spots on and off for ten days
DIAGNOSTIC ERRORS IN EXTRA-UTERINE PREGNANCY
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afterward is probably pregnant. Had she bled profusely for the last ten days the same suspicion would hold, particularly if we could elicit the fact that she had gone over her last menstrual period a few days or a week before this abnormal bleeding began. Were the patient married we would be less suspicious of a basis for deception, although there might well be, even then, a reason why the patient might deny the possibility of pregnancy. We will examine her, but what findings can there be this early in pregnancy to guide us? Can you find enough enlargement in a uterus of an unknown patient ten days after the expected period to make a diagnosis? Rarely. If then it is an ectopic pregnancy would you be able to feel an enlargement of the tube? You would not. Then why examine her if you can anticipate no findings.. Well, we'll do it anyway, maybe we will find something, who knows? The vagina easily admits 2 fingers without discomfort. That's one finding. The cervix is small-not softened, and the body of the uterus is smaller than normal, so small that one could be almost certain that it holds no pregnancy. We will now palpate the region of the tubes and ovaries. I can feel the left ovary as normal, on the right side I feel nothing but I elicit a lot of tenderness. We will make a rectovaginal examination as should be done in every case examined for the first time for the rectal finger can go higher than the vaginal vault and frequently picks up findings missed by vaginal examination. No-we find nothing in the appendages. We found no swelling of the ovary so we are not dealing with a torsion of an ovarian cyst which gives a similar picture of acute pain associated with a leukocytosis, and no temperature until the torsion has existed so long that gangrene of the cyst occurs. Nor is there a corpus luteum cyst which in early pregnancy is frequently mistaken for appendicitis or for an ectopic pregnancy. Let us now review our history and our findings. We have a young lady with roomy vagina who ten days ago had what she called a period but the bleeding was scanty, of short duration and reappeared at irregular intervals as spotting up until the present time-this is very suspicious of pregnancy. She has a leukocytosis of 18,000. If the leukocytosis were due to appendicitis then the appendix would be acutely inflamed and
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we would have elevated temperature, which we have not, therefore we have no appendicitis. A catheterized specimen of urine is free of pus and red cells which excludes a ureteral attack. We have no swellings, which excludes inflammation and torsion and corpus luteum cyst. We have a patient whose last normal period was about five and one-half weeks ago, who has had abnormal bleeding with seizures of severe pain with leukocytosis. The leukocytosis is higher than we get in early pregnancy; it could be due to hemorrhage into the abdominal cavity in an amount insufficient to produce shock but sufficient to produce a leukocytosis. You are well acquainted with the fact that hemorrhage into the abdomen may produce a marked leukocytosis. We said that the uterus is so small that its very size almost precludes the probability of an ovum being in it. We believe the patient is pregnant, if it is not in the uterus then it must be in the appendage. And remember that one of the causes of ectopic pregnancy is undeveloped tubes. When the tube is very small its lumen may be too small to allow the egg to pass so it lodges and embeds itself. There is no way of determining that this patient's tubes are small, yet if her uterus is very small her tubes are probably proportionately small. Be on your guard for ectopic pregnancy when in the presence of pregnancy symptoms you find a tiny uterus. Now, what will we do in this case? We have a young woman where we suspect an ectopic pregnancy yet she is not ill enough to justify a laparotomy particularly in the absence of pelvic findings. Nausea, abnormal cravings, enlargement of the breasts, and colostrum what of them? We would not expect to find them this early in a normal pregnancy-their absence in this case means nothing. An Aschheim-Zondek test we have started. What if it is negative? We know that at this early stage it is frequently negative when later the patient proves to be pregnant and reacts positively. What will we do with this case? Put her back to bed on observation? To watch her for what? Enlargement of the pregnant tube? If she has an ectopic pregnancy this pain, transitory faintness and leukocytosis means that she has had a partial rupture or a partial tubal abortion. How long will it take for the tube to get big enough to palpate? So long that the patient will probably have a complete rupture before
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that time comes. Most tubes rupture before they ever get big .enough to feel. In this clinic we do not put suspected ectopic pregnancies to bed for observation. The history here is that of an early disturbed pregnancy, that is reasonably certain, either a disturbed uterine pregnancy or an ectopic. The abnormally small uterus, the typical pain and the leukocytosis make it very suspicious of an ectopic pregnancy. I am not going to put this patient back to bed on observation-I have had her prepared both abdominally and vaginally for operation and, first of all, I am going to dilate and curette the uterus for if it is a uterine pregnancy it is disturbed and not worth saving anyway. The cervix dilates like a nonpregnant uterus. Gently curetting I get no scrapings. Now the good textbooks tell us that if the scrapings from a pregnant woman are examined villi will be found when the pregnancy is uterine, and no villi will be found if an ectopic pregnancy is present. That sounds very simple. If villi are found there can be no question' of the pregnancy being uterine for villi are fetal in origin. When, however, you find no villi in uterine scrapings you cannot say that there is no uterine pregnancy present unless the uterus has been thoroughly emptied and unless all the scrapings obtained have been thoroughly examined. The curettings obtained in an early pregnancy may be scraped from an area too far from the embedding place of the ovum to show villi and consequently the tissue in the sections may not contain villi. One must save all the tissue obtained and all tissue must be examined thoroughly before the absence of villi can be held of any importance. The textbooks do not tell you what to do if you get no scrapings. No uterine pregnancy ever aborts so completely that if you curette the uterus while the patient is still bleeding you will not get abundant scrapings. The fewer the scrapings obtained the more probable the ectopic pregnancy. If you get a dry scrape an ectopic pregnancy is almost certain. Now remember that fact. If you curette a case of what you have thought to be a threatened or incomplete abortion and you get a dry scrape it is not because you got there too late, it is because you are probably dealing with an ectopic pregnancy. Quite true that the endometrium undergoes a decidual reaction and thickens in ectopic pregnancy and that
218
N. SPROAT HEANEY
if you examine the scrapings you get typical decidual reaction, that is, if you get any scrapings. By the time most ectopic pregnancies get to the operating table the uterus has expelled I do? all the decidua and you get a dry scrape. Now what I have a patient in whom I have diagnosed a pregnancy stating that it is either an early disturbed uterine pregnancy or an ectopic pregnancy. Curettage gave us no scrapings-it is therefore not a uterine pregnancy but an ectopic pregnancy. Shall I put her flat and go into the abdomen by a midline incision? I think not-I should like a little more certainty that there really is an ectopic pregnancy. I am a little too cagey when symptoms are no more outspoken than these to plump myself into a laparotomy. Looking back over a considerable period of years I can remember visiting clinics a good many times where, under exactly similar conditions, the diagnosis of an ectopic pregnancy has been made and a laparotomy has been performed with dispatch and certainty and no ectopic pregnancy has been found. One of you suggests that I use an aspirating needle to see if I get blood in the cul-de-sac. What am I going to aspirate? I have no swellings to stick and it is dangerous to shove a needle through the fornix hoping that I will land by a stroke of luck in a pool of blood. When you have a definite swelling and fluctuation is undoubtedly present I have no objection to using a large caliber aspirating needle under the guidance of a finger in the rectum to see whether fluid may be obtained. If I get fluid I have gone a step forward in diagnosis. However, it is not at all exceptional that when I am dead certain that I have an abscess in the cul-de-sac or a hematoma in the broad ligament I fail to get anything upon aspiration because the substance is too thick to pass through the needle. I have in mind many cases where aspiration failed to show pus, yet puncture with a pair of sharp scissors yielded abundant pus. However, aspirating a mass is one thing and trying to strike free -blood in the cul-de-sac is another. Palpation here shows a roomy nulliparous vagina, a freely movable uterus and a roomy cul-de-sac. I am going to make a colpotomy incision and see if an ectopic pregnancy is present. I pull the cervix well down with a bullet forceps and then strongly forward toward the symphysis. With a tissue forceps
will
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I pick up the vaginal mucous membrane in the fornix. Just posterior to where the mucosa is attached to the body of the cervix I make a transverse incision about 1 inch wide. I take care not to open the cul-de-sac at one fell swoop-I may enter the rectum instead. Now I push the posterior edge of the incised mucous membrane backward % inch or so and I see now the thin peritoneum showing through. Frequently, if considerable blood is present in the cul-de-sac, particularly if it has been there for some time, this bUlging peritoneum will be bluish or greenish. Here there is no discoloration. There is a tiny spurter underneath the mucosa here which I will tie off because I want the wound to be dry the moment I incise the peritoneum. If there is any blood in the cul-de-sac I want to be certain whether it came from the peritoneal cavity or from my incIslOn. I now incise the peritoneum and look quickly and there escapes through the incision a teaspoonful or more of bright blood. It is almost a certainty that I am dealing with an ectopic pregnancy. Occasionally a ruptured corpus luteum will give free bleeding. Had I got no blood I would, nevertheless, have introduced a pair of narrow-bladed Lshaped special vaginal retractors, put the patient in somewhat elevated lithotomy position and looked at the ovaries and tubes. Had I found no ectopic pregnancy I would have sewn the incision up with 3 or 4 interrupted chromic catgut sutures and the patient would have been no worse off than with the curettage alone and would have had to stay no longer in the hospital nor would she ordinarily have been any sicker than after a simple curettage. I have, however, found free blood and I can either search further to see just where the pregnancy is or I can close the incision, put the patient flat and enter the abdomen with every certainty that I am not performing a laparotomy with all its potential possibilities unnecessarily. Making a colpotomy incision is a triviality by comparison.· One of you states that having entered the pelvis by colpotomy you would hesitate now to go in from above because of contamination. How do you mean contamination? This vagina was very thoroughly scrubbed, the cervix was free of infection and after the curettage the uterine cavity was swabbed out with iodine and the vagina was very thoroughly iodized. Some of you cer-
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tainly have peculiar ideas, likening the vagina to a cesspool. Where do you get that way! Get over your timidity regarding the danger of an exploratory colpotomy. I think it is one of the most important technics that a gynecologist can have at his disposal and I am certain that if all gynecologists familiarized themselves with it they would save their patients many unnecessary laparotomies. Afraid to go into the abdomen from above after simple colpotomy! What will you say when I state that very frequently in complete hysterectomies, for one reason or another, for example a badly infected cervix with a low, broad fibroid pressing against the rectum, I remove the cervix from below after opening both anterior and posterior cul-de-sacs and, then after closing the vaginal vault, that I enter the abdomen by laparotomy for the removal of the rest of the uterus. Yes, and frequently to the patient's great benefit. Never have I seen anything in the postoperative course of such a patient to make me think that I had contaminated the pelvis in any way. This pregnancy is a very early one and the patient is not bleeding freely so my vision will probably not be interfered with so I think I will see if I am able to remove this pregnancy through the vagina. With the narrow-bladed retractors still in place I widen the incision from the sacro-uterine ligament on one side to the opposite one. I now place a bullet forceps transversely through the cervix just anterior to the incision and pull rather strongly downward and forward toward the symphysis-this tends to make the uterine body rotate posteriorly. I now remove the anterior retractor and with a bullet forceps reach through the incision and under the guidance of the eye take a hold on the posterior wall of the uterus. Now the bullet forceps is removed from the cervix and the one on the posterior wall of the uterus is pulled so as to draw the body of the uterus toward the incision. As the uterine body presents itself other bites are taken until either the body is delivered into the vagina or the right uterine horn is thoroughly exposed. The fixed portion of the tube is now visible and the remainder of the tube is gently drawn into the incision by tissue forceps. Here in the distal third we see a bluish swelling of the tube the length and thickness of the distal phalanx of my little finger-there is our ectopic preg-
DIAGNOSTIC ERRORS IN EXTRA-UTERINE PREGNANCY
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nancy! Who of you is so clever that you can palpate a pregnancy of that size by vaginal examination? There is no rupture present but you see blood freely oozing from the tubal ostium. I ligate the blood supply of the distal portion of the tube and loosen the tube from its mesentery. I now excise the rest of the tube from the uterus and pick up all bleeding vessels with a running suture. The opposite tube and ovary are now searched for, are found and look normal. The uterus is now released, the body pushed back into the pelvis and the incision closed with through-and-through interrupted No. 2 ten-day chromic catgut after having wiped the cul-de-sac free of blood. This operation was successfully completed by the vaginal route but I would have deserted this route at any moment that I thought my difficulties could be more readily solved by laparotomy, for the abdomen was prepared for that possibility before we did the curettage. This patient will be kept in bed one week and, barring the unexpected, will be able to leave the hospital on the tenth day. I confidently predict that she will eat and retain all her meals tomorrow and will have a far easier convalescence than if I had entered her abdomen from above. I am not advising you to try to operate your ectopic cases by the vaginal route. I am, however, telling you that when the diagnosis lies between a clean, incomplete or imminent abortion and ectopic pregnancy to curette the uterus on the basis that persistent bleeding indicates a pregnancy not worth saving and that if you get a dry scrape to change the diagnosis to ectopic pregnancy. I am also advising you that where the symptoms are no more pronounced than they were in this case to save yourself the embarrassment of a mistaken diagnosis and the patient the danger of an unnecessary laparotomy by doing an exploratory colpotomy for diagnostic purposes. This case teaches a homely everyday fact which those who treat women should always bear in mind-the usual and ordinary cause of a single abnormal so-called "menstrual period" is pregnancy.
CLINIC OF DR. N. SPROAT HEANEY PRESBYTERIAN HOSPITAL
DIAGNOSTIC ERRORS IN EXTRA-UTERINE PREGNANCY
I HAVE a very interesting case to present this morning. This patient is a young single woman sent to us for the removal of her appendix because of right-sided pain associated with a leukocytosis pf 18,000. This young woman of twenty-six has always been perfectly well and sturdy until the onset of the present difficulty yesterday early. While at stool after breakfast she had a rather sharp pain in the right side, transitory in nature, which, though short in duration, left her exhausted. The bowel movement was formed and was accompanied by no unusual amount of gas. The patient had a formed bowel movement again this morning so we can rule out bowel colic as the cause of her pain rather certainly. At noon yesterday after eating heartily she had another seizure of pain of similar character somewhat sharper but also short in duration. Early this morning a third attack of pain occurred still more intense and at that time she called a physician who found her tender over the region of the appendix. He made a leukocyte count and found it 18,000 while her temperature and pulse were normal. Now, this patient is before us and not one word has been said by her attending physician nor by the intern, who took her history, about her menstrual periods. How many errors in medicine are attributable to that lapse. I want to tell you that you will be wise to take a menstrual history on every woman you are called upon to treat. It may be thought that a brain tumor is present and is producing vomiting until a menstrual history with subsequent examination shows that the vomiting is due to an ordinary common everyday pregnancy. 21 3
N. SPROAT HEANEY
You may be a skin man treating a case of baffling urticaria until a menstrual history shows that the patient is pregnant and the urticaria is toxic in origin. When we question this patient about her menses she states that she has been always regular every twenty-eight days and that her last menstrual period was ten days ago and on time. If you want to avoid frequent and important errors in gynecologic diagnosis you must not take a statement to the effect that the last period was on time and normal in every way, without a bit of doubt. Every woman will stand a little cross examination on this point. First of all, if a woman really menstruates every twenty-eight days on the dot then she must necessarily begin menstruating each time on the same day of the week. Occasionally a woman· is that regular, but most are not. This woman says that she does not always begin to menstruate on the same day of the week so immediately we know that her last menstrual period's regularity is questionable; it may have been a few days late without attracting her attention. She states that the period was normal but when we examine into details she says that while she normally menstruates always for four or five days and uses 10 to 12 pads that this time she "menstruated" very scantily for three days then stopped entirely for a day or two and then began spotting, and that this spotting has continued until now. Gentlemen, this is a very suspicious symptom in a woman complaining of "appendicitis." When I asked this patient if there were any chance of her being pregnant she was indignant at the suggestion. This proves nothing, however. If she had said there was, it would have been contributing testimony; her denial means nothing. Last week I saw a girl close to term where the fetal parts could be mapped out and where you could hear the unmistakable fetal heart and could see the baby lunge about and yet she insisted that I was in error. So we will not allow the history in this regard to influence us. So we will proceed to our examination to prove that this patient who has been regular all her life, menstruating each month for five days and each time freely, and for a like amount each month, but who ten days ago had an abnormal period, is not pregnant. My belief is that she is, for any woman who has a scanty "period" and then spots on and off for ten days
DIAGNOSTIC ERRORS IN EXTRA-UTERINE PREGNANCY
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afterward is probably pregnant. Had she bled profusely for the last ten days the same suspicion would hold, particularly if we could elicit the fact that she had gone over her last menstrual period a few days or a week before this abnormal bleeding began. Were the patient married we would be less suspicious of a basis for deception, although there might well be, even then, a reason why the patient might deny the possibility of pregnancy. We will examine her, but what findings can there be this early in pregnancy to guide us? Can you find enough enlargement in a uterus of an unknown patient ten days after the expected period to make a diagnosis? Rarely. If then it is an ectopic pregnancy would you be able to feel an enlargement of the tube? You would not. Then why examine her if you can anticipate no findings.. Well, we'll do it anyway, maybe we will find something, who knows? The vagina easily admits 2 fingers without discomfort. That's one finding. The cervix is small-not softened, and the body of the uterus is smaller than normal, so small that one could be almost certain that it holds no pregnancy. We will now palpate the region of the tubes and ovaries. I can feel the left ovary as normal, on the right side I feel nothing but I elicit a lot of tenderness. We will make a rectovaginal examination as should be done in every case examined for the first time for the rectal finger can go higher than the vaginal vault and frequently picks up findings missed by vaginal examination. No-we find nothing in the appendages. We found no swelling of the ovary so we are not dealing with a torsion of an ovarian cyst which gives a similar picture of acute pain associated with a leukocytosis, and no temperature until the torsion has existed so long that gangrene of the cyst occurs. Nor is there a corpus luteum cyst which in early pregnancy is frequently mistaken for appendicitis or for an ectopic pregnancy. Let us now review our history and our findings. We have a young lady with roomy vagina who ten days ago had what she called a period but the bleeding was scanty, of short duration and reappeared at irregular intervals as spotting up until the present time-this is very suspicious of pregnancy. She has a leukocytosis of 18,000. If the leukocytosis were due to appendicitis then the appendix would be acutely inflamed and
216
N. SPROAT HEANEY
we would have elevated temperature, which we have not, therefore we have no appendicitis. A catheterized specimen of urine is free of pus and red cells which excludes a ureteral attack. We have no swellings, which excludes inflammation and torsion and corpus luteum cyst. We have a patient whose last normal period was about five and one-half weeks ago, who has had abnormal bleeding with seizures of severe pain with leukocytosis. The leukocytosis is higher than we get in early pregnancy; it could be due to hemorrhage into the abdominal cavity in an amount insufficient to produce shock but sufficient to produce a leukocytosis. You are well acquainted with the fact that hemorrhage into the abdomen may produce a marked leukocytosis. We said that the uterus is so small that its very size almost precludes the probability of an ovum being in it. We believe the patient is pregnant, if it is not in the uterus then it must be in the appendage. And remember that one of the causes of ectopic pregnancy is undeveloped tubes. When the tube is very small its lumen may be too small to allow the egg to pass so it lodges and embeds itself. There is no way of determining that this patient's tubes are small, yet if her uterus is very small her tubes are probably proportionately small. Be on your guard for ectopic pregnancy when in the presence of pregnancy symptoms you find a tiny uterus. Now, what will we do in this case? We have a young woman where we suspect an ectopic pregnancy yet she is not ill enough to justify a laparotomy particularly in the absence of pelvic findings. Nausea, abnormal cravings, enlargement of the breasts, and colostrum what of them? We would not expect to find them this early in a normal pregnancy-their absence in this case means nothing. An Aschheim-Zondek test we have started. What if it is negative? We know that at this early stage it is frequently negative when later the patient proves to be pregnant and reacts positively. What will we do with this case? Put her back to bed on observation? To watch her for what? Enlargement of the pregnant tube? If she has an ectopic pregnancy this pain, transitory faintness and leukocytosis means that she has had a partial rupture or a partial tubal abortion. How long will it take for the tube to get big enough to palpate? So long that the patient will probably have a complete rupture before
DIAGNOSTIC ERRORS IN EXTRA-UTERINE PREGNANCY
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that time comes. Most tubes rupture before they ever get big .enough to feel. In this clinic we do not put suspected ectopic pregnancies to bed for observation. The history here is that of an early disturbed pregnancy, that is reasonably certain, either a disturbed uterine pregnancy or an ectopic. The abnormally small uterus, the typical pain and the leukocytosis make it very suspicious of an ectopic pregnancy. I am not going to put this patient back to bed on observation-I have had her prepared both abdominally and vaginally for operation and, first of all, I am going to dilate and curette the uterus for if it is a uterine pregnancy it is disturbed and not worth saving anyway. The cervix dilates like a nonpregnant uterus. Gently curetting I get no scrapings. Now the good textbooks tell us that if the scrapings from a pregnant woman are examined villi will be found when the pregnancy is uterine, and no villi will be found if an ectopic pregnancy is present. That sounds very simple. If villi are found there can be no question' of the pregnancy being uterine for villi are fetal in origin. When, however, you find no villi in uterine scrapings you cannot say that there is no uterine pregnancy present unless the uterus has been thoroughly emptied and unless all the scrapings obtained have been thoroughly examined. The curettings obtained in an early pregnancy may be scraped from an area too far from the embedding place of the ovum to show villi and consequently the tissue in the sections may not contain villi. One must save all the tissue obtained and all tissue must be examined thoroughly before the absence of villi can be held of any importance. The textbooks do not tell you what to do if you get no scrapings. No uterine pregnancy ever aborts so completely that if you curette the uterus while the patient is still bleeding you will not get abundant scrapings. The fewer the scrapings obtained the more probable the ectopic pregnancy. If you get a dry scrape an ectopic pregnancy is almost certain. Now remember that fact. If you curette a case of what you have thought to be a threatened or incomplete abortion and you get a dry scrape it is not because you got there too late, it is because you are probably dealing with an ectopic pregnancy. Quite true that the endometrium undergoes a decidual reaction and thickens in ectopic pregnancy and that
218
N. SPROAT HEANEY
if you examine the scrapings you get typical decidual reaction, that is, if you get any scrapings. By the time most ectopic pregnancies get to the operating table the uterus has expelled I do? all the decidua and you get a dry scrape. Now what I have a patient in whom I have diagnosed a pregnancy stating that it is either an early disturbed uterine pregnancy or an ectopic pregnancy. Curettage gave us no scrapings-it is therefore not a uterine pregnancy but an ectopic pregnancy. Shall I put her flat and go into the abdomen by a midline incision? I think not-I should like a little more certainty that there really is an ectopic pregnancy. I am a little too cagey when symptoms are no more outspoken than these to plump myself into a laparotomy. Looking back over a considerable period of years I can remember visiting clinics a good many times where, under exactly similar conditions, the diagnosis of an ectopic pregnancy has been made and a laparotomy has been performed with dispatch and certainty and no ectopic pregnancy has been found. One of you suggests that I use an aspirating needle to see if I get blood in the cul-de-sac. What am I going to aspirate? I have no swellings to stick and it is dangerous to shove a needle through the fornix hoping that I will land by a stroke of luck in a pool of blood. When you have a definite swelling and fluctuation is undoubtedly present I have no objection to using a large caliber aspirating needle under the guidance of a finger in the rectum to see whether fluid may be obtained. If I get fluid I have gone a step forward in diagnosis. However, it is not at all exceptional that when I am dead certain that I have an abscess in the cul-de-sac or a hematoma in the broad ligament I fail to get anything upon aspiration because the substance is too thick to pass through the needle. I have in mind many cases where aspiration failed to show pus, yet puncture with a pair of sharp scissors yielded abundant pus. However, aspirating a mass is one thing and trying to strike free -blood in the cul-de-sac is another. Palpation here shows a roomy nulliparous vagina, a freely movable uterus and a roomy cul-de-sac. I am going to make a colpotomy incision and see if an ectopic pregnancy is present. I pull the cervix well down with a bullet forceps and then strongly forward toward the symphysis. With a tissue forceps
will
DIAGNOSTIC ERRORS IN EXTRA-UTERINE PREGNANCY
219
I pick up the vaginal mucous membrane in the fornix. Just posterior to where the mucosa is attached to the body of the cervix I make a transverse incision about 1 inch wide. I take care not to open the cul-de-sac at one fell swoop-I may enter the rectum instead. Now I push the posterior edge of the incised mucous membrane backward % inch or so and I see now the thin peritoneum showing through. Frequently, if considerable blood is present in the cul-de-sac, particularly if it has been there for some time, this bUlging peritoneum will be bluish or greenish. Here there is no discoloration. There is a tiny spurter underneath the mucosa here which I will tie off because I want the wound to be dry the moment I incise the peritoneum. If there is any blood in the cul-de-sac I want to be certain whether it came from the peritoneal cavity or from my incIslOn. I now incise the peritoneum and look quickly and there escapes through the incision a teaspoonful or more of bright blood. It is almost a certainty that I am dealing with an ectopic pregnancy. Occasionally a ruptured corpus luteum will give free bleeding. Had I got no blood I would, nevertheless, have introduced a pair of narrow-bladed Lshaped special vaginal retractors, put the patient in somewhat elevated lithotomy position and looked at the ovaries and tubes. Had I found no ectopic pregnancy I would have sewn the incision up with 3 or 4 interrupted chromic catgut sutures and the patient would have been no worse off than with the curettage alone and would have had to stay no longer in the hospital nor would she ordinarily have been any sicker than after a simple curettage. I have, however, found free blood and I can either search further to see just where the pregnancy is or I can close the incision, put the patient flat and enter the abdomen with every certainty that I am not performing a laparotomy with all its potential possibilities unnecessarily. Making a colpotomy incision is a triviality by comparison.· One of you states that having entered the pelvis by colpotomy you would hesitate now to go in from above because of contamination. How do you mean contamination? This vagina was very thoroughly scrubbed, the cervix was free of infection and after the curettage the uterine cavity was swabbed out with iodine and the vagina was very thoroughly iodized. Some of you cer-
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tainly have peculiar ideas, likening the vagina to a cesspool. Where do you get that way! Get over your timidity regarding the danger of an exploratory colpotomy. I think it is one of the most important technics that a gynecologist can have at his disposal and I am certain that if all gynecologists familiarized themselves with it they would save their patients many unnecessary laparotomies. Afraid to go into the abdomen from above after simple colpotomy! What will you say when I state that very frequently in complete hysterectomies, for one reason or another, for example a badly infected cervix with a low, broad fibroid pressing against the rectum, I remove the cervix from below after opening both anterior and posterior cul-de-sacs and, then after closing the vaginal vault, that I enter the abdomen by laparotomy for the removal of the rest of the uterus. Yes, and frequently to the patient's great benefit. Never have I seen anything in the postoperative course of such a patient to make me think that I had contaminated the pelvis in any way. This pregnancy is a very early one and the patient is not bleeding freely so my vision will probably not be interfered with so I think I will see if I am able to remove this pregnancy through the vagina. With the narrow-bladed retractors still in place I widen the incision from the sacro-uterine ligament on one side to the opposite one. I now place a bullet forceps transversely through the cervix just anterior to the incision and pull rather strongly downward and forward toward the symphysis-this tends to make the uterine body rotate posteriorly. I now remove the anterior retractor and with a bullet forceps reach through the incision and under the guidance of the eye take a hold on the posterior wall of the uterus. Now the bullet forceps is removed from the cervix and the one on the posterior wall of the uterus is pulled so as to draw the body of the uterus toward the incision. As the uterine body presents itself other bites are taken until either the body is delivered into the vagina or the right uterine horn is thoroughly exposed. The fixed portion of the tube is now visible and the remainder of the tube is gently drawn into the incision by tissue forceps. Here in the distal third we see a bluish swelling of the tube the length and thickness of the distal phalanx of my little finger-there is our ectopic preg-
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nancy! Who of you is so clever that you can palpate a pregnancy of that size by vaginal examination? There is no rupture present but you see blood freely oozing from the tubal ostium. I ligate the blood supply of the distal portion of the tube and loosen the tube from its mesentery. I now excise the rest of the tube from the uterus and pick up all bleeding vessels with a running suture. The opposite tube and ovary are now searched for, are found and look normal. The uterus is now released, the body pushed back into the pelvis and the incision closed with through-and-through interrupted No. 2 ten-day chromic catgut after having wiped the cul-de-sac free of blood. This operation was successfully completed by the vaginal route but I would have deserted this route at any moment that I thought my difficulties could be more readily solved by laparotomy, for the abdomen was prepared for that possibility before we did the curettage. This patient will be kept in bed one week and, barring the unexpected, will be able to leave the hospital on the tenth day. I confidently predict that she will eat and retain all her meals tomorrow and will have a far easier convalescence than if I had entered her abdomen from above. I am not advising you to try to operate your ectopic cases by the vaginal route. I am, however, telling you that when the diagnosis lies between a clean, incomplete or imminent abortion and ectopic pregnancy to curette the uterus on the basis that persistent bleeding indicates a pregnancy not worth saving and that if you get a dry scrape to change the diagnosis to ectopic pregnancy. I am also advising you that where the symptoms are no more pronounced than they were in this case to save yourself the embarrassment of a mistaken diagnosis and the patient the danger of an unnecessary laparotomy by doing an exploratory colpotomy for diagnostic purposes. This case teaches a homely everyday fact which those who treat women should always bear in mind-the usual and ordinary cause of a single abnormal so-called "menstrual period" is pregnancy.