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Operative management of ruptured tubal pregnancy
Operative management of ruptured tubal pregnancy J.
D.
HARRALSON,
J.
R.
VAN
J.
W.
M.D.
NAGELL,
JR.,
RODDICK,
Lexington,
JR.,
M.D.* M.D.
Kentucky
Ruptured ectopic pregnancy constitutes a major gynecologic emergency and is responsible for a significant percentage of gynecologic mortality in the United States of America. From 1964 to 1971, 96 patients with ruptured tubal pregnancy were treated at the University of Kentucky Medical Center and affiliated hospitals. Of these patients, four had previous tubal pregnancies and five had prior tubal ligations; 41 had microscopic evidence of pelvic inflammatory disease. The incidence of postoperative morbidity was 2.5 per cent and there was one death. Types of surgical procedures utilized are discussed, and the criteria for hysterectomy with salpingectomy as the operation of choice in the treatment of ruptured tubal pregnancy are presented.
Ec~opIc pregnancyrepresents a major gynecologic emergency and presently accounts for six to seven per cent of gynecologic deaths.l At present, most ruptured tubal pregnancies are treated by either unilateral salpingectomy or salpingo-oophorectomy.‘. 3 The purpose of this study is to review the treatment of ruptured tubal pregnancy at one institution. The use of hysterectomy with salpingectomy as a method in the suqical management of these patients is discussed.
incidence of one ruptured tubal pregnancy per 230 live births. The average age of the patients was 27 years and the average gravidity 2.8 (Table I). The most common presenting symptoms were lower abdominal pain and vaginal bleeding following a missed or scant menstrual period. The presrbnce of hemoperitoneum was confirmed by culdocentesis in 60 per cent of the patients. Ruptured ectopic pregnancy was confirmed by colpotomy in 10 per cent of the cases and by laparotomy in the remainder. Twenty-five per cent of the patients had had one or more previous abortions and four patients had had a previous ectopic pregnancy. Microscopic evidence of follicular or interstitial salpingitis was present in 42 per cent of the cases. Previous bilateral partial salpingectomy for sterilization had been performed on five patients. Eighty-one patients were treated by means of unilateral salpingectomy (36 ol’ tht:sc also had unilateral oophorectomy ) . and 15 by hysterectomy with salpingectomy (four also had unilateral oophorectomy) (Table II). The average volume of intraperitoneal blood present prior to operation was 375 ml.
RUPTURED
Methods
and
results
From 1964 to 1971, 96 patients with ruptured tubal pregnancy were treated at the University of Kentucky Medical Center and affiliated hospitals. During the same time period, there were 22,428 live births-an
From the Department Gynecology, University Medical Center. Received
for
Accepted
October
*Junior American
of Obstetrics of Kentucky
publication
July
and
31, 1972.
2, 1972.
Faculty Clinical Fellow, Cancer Society. 995
996
Table
Harralson,
van
Nagell,
and
I. Basic characteristics
Roddick
of group
Table IV. Morbidity function of operative
and hospital procedure
stay as a
Operation
Salpingectomy or salpingo-oophorectomy Hysterectomy with salpingectomy or salpingo-oophorectomy Total
Table II. Type tubal pregnancy
81
26.5
15 G
2.8
-29.9 27.0
of operation
-2.8 2.8
Table
for ruptured
45 36
46.9 37.5
15
15.6 100
ss
Table
III.
Findings
at operation Pelvic infiammatory disease (%)
Salpingectomy or salpingo-oophorectomy Hysterectomy with salpingectomy or salpingo-oophorectomy Total
V. Postoperative
33
6.2
33
7.0
25
6.3
morbidity
Morbidity ~~- 1:~~;z?;
Patients IX-T-T-
Unilateral salpingectomy Unilateral salpingo-oophorectomy Hysterectomy with salpingectomy or salpingo-oophorectomy
Salpingectomy or salpingooophorectomy Hysterectomy with salpingectomy or salpingooophorectomy Total
Zntraperitoneal preoperative blood loss (ml.1
38
815
62
375
-Ti
746
Urinary tract infection Pneumonia, atelectasis Wound infection Pelvic cellulitis Peritonitis Total
2
13.2
8
9.8
0
0
6
7.4
1
6.7
2
2.5
6.7 - 6.7 33.3
3 -0 19/81
1 -1 5/15
3.7 __0 23.4
lowing unilateral salpingectomy of pulmonary failure secondary to intraoperative aspiration pneumonitis. Comment
in the hysterectomy group and 815 ml. in the salpingectomy group (Table III). Blood loss directly attributable to operation was 290 ml. for hysterectomy and 150 ml. for salpingectomy or salpingo-oophorectomy. The mean postoperative febrile morbidity was higher in the hysterectomy group (Table IV), although the total number of postoperative days was increased only from 6.2 to 7.0 days. The most common causes of postoperative febrile morbidity were urinary tract infection, atelectasis, and pelvic infection (Table V) . The single death occurred in a 26-year-old primigravida who died on the fifth day fol-
The incidence of tubal pregnancy at this institution is lower than that reported in other large series, and may reflect the low incidence of pelvic inflammatory disease in the referral population. Nevertheless, microscopic observation of pelvic inflammation in 42 per cent of cases correlates closely with that reported by other investigators.5, ($ The diagnosis of ruptured ectopic pregnancy was suggested most commonly by culdocentesis. Colpotomy was performed only in those cases in which culdocentesis was equivocal. Twenty-one patients were hypotensive and had an intraperitoneal blood loss of 1,500 ml. or more. These patients were operated upon immediately after admission, without culdocentesis or colpotomy. The incidence of patients with ruptured
Operative
tubal, pregnancy following tubal ligation (4.2 per cent) is higher in this study than in previous reports. Breen,l for example, found that ectopic pregnancy was preceded by tubal ligation in less than one per cent of cases. It should be emphasized that a history of previous tubal ligation should not delay performance of the necessary diagnostic procedures to confirm the presence of ruptured tubal pregnancy. Prystowsky and Eastman7 for example, noted that ectopic pregnancies occurred in over 20 per cent of puerperal tubal ligation failures. Hysterectomy with salpingectomy is being used with increasing frequency in the treatment of ruptured ectopic pregnancy. Webster and Barclay,l” in a study of ectopic pregnancies at New Orleans Charity Hospital, reported that hysterectomy at the time of salpingectomy was performed in 10.7 per cent of patients from 1947 to 1950 and in over 42 per cent from 1959 to 1963. In general, the following conditions should exist before hysterectomy is undertaken: ( 1) the patient should have had a normal cervical cytologic smear within six months prior to operation, (2) intraperitoneal blood loss should not be excessive, and (3) the patient’s vital signs must be stable. The incidence of cervical epithelial abnormality in women of reproductive age is 15 to 20 per thousand.8 Therefore, hysterectomy without prior cervical cytologic smears may result in the removal of an occult invasive cervical carcinoma. Average
management
of ruptured
tubal
pregnancy
997
intraperitoneal blood loss prior to operation in the hysterectomy group was less than half that in the salpingectomy group (Table III). All patients had stable vital signs before hysterectomy was initiated as well as throughout the operative procedure. Indications for hysterectomy with salpingectomy include sterilization, pelvic inflammatory disease with visible destruction of both uterine tubes, previous bilateral tubal ligation or ectopic pregnancy, uterine leiomyomas, and ovarian tumors. Although operative blood loss, morbidity, and postoperative hospital stay were all slightly increased in the hysterectomy group, several advantages are apparent. Recurrent ectopic pregnancy has been reported to occur in six to 15 per cent of other series.l’ 3, lo In addition, patients with ectopic pregnancy tend to be of lower socioeconomic status, and have a higher incidence of pelvic inflammatory disease and uterine pathology requiring subsequent operative intervention.* The authors do not suggest that hysterectomy should routinely be performed in patients with ruptured tubal pregnancy. The incidence of normal pregnancy following salpingectomy is as high as 50 per cent.H Nevertheless, in the multiparous patient who has had pelvic inflammatory disease or previous tubal surgery, hysterectomy with salpingectomy may be the procedure of choice in the operative management of ruptured tubal pregnancy.
REFERENCES
1. Breen, J. L.: 1004, 1970. 2. Culton, Y., Gvnecol. 29: 3. H&pin, T.: 227, 1970. 4. Haynes, D. OBSTET.
5.
Kleiner, GYNECOL.
AM.
J. OBSTET.
GYNECOL.
106:
and van Ostrand, J.: Obstet. 279. 1967. AM.’ J. OBSTET. GYNECOL. 106:
6. 7. 8. 9.
M.,
and
Wolfe, W. M.: AM. J. GYNECOL. 106: 1044, 1970. G., and Roberts, T.: AM. J. OBSTET. 99: 21, 1967.
10.
Persaud, V.: Obstet. Gynecol. 36: 257, 1970. Prystowsky, H., and Eastman, N. J.: J. A. M. A. 158: 463, 1955. Stern, E., and Neely, P. M.: Acta Cytol. 7: 357, 1963. Timonen, S., and Nieminen, A.: Acta Obstet. Gynecol. Stand. 46: 327, 1967. Webster, H. D., and Barclay, D.: Aw. J. OBSTET. GYNECOL. 92: 23, 1965.
D.
HARRALSON,
J.
R.
VAN
J.
W.
M.D.
NAGELL,
JR.,
RODDICK,
Lexington,
JR.,
M.D.* M.D.
Kentucky
Ruptured ectopic pregnancy constitutes a major gynecologic emergency and is responsible for a significant percentage of gynecologic mortality in the United States of America. From 1964 to 1971, 96 patients with ruptured tubal pregnancy were treated at the University of Kentucky Medical Center and affiliated hospitals. Of these patients, four had previous tubal pregnancies and five had prior tubal ligations; 41 had microscopic evidence of pelvic inflammatory disease. The incidence of postoperative morbidity was 2.5 per cent and there was one death. Types of surgical procedures utilized are discussed, and the criteria for hysterectomy with salpingectomy as the operation of choice in the treatment of ruptured tubal pregnancy are presented.
Ec~opIc pregnancyrepresents a major gynecologic emergency and presently accounts for six to seven per cent of gynecologic deaths.l At present, most ruptured tubal pregnancies are treated by either unilateral salpingectomy or salpingo-oophorectomy.‘. 3 The purpose of this study is to review the treatment of ruptured tubal pregnancy at one institution. The use of hysterectomy with salpingectomy as a method in the suqical management of these patients is discussed.
incidence of one ruptured tubal pregnancy per 230 live births. The average age of the patients was 27 years and the average gravidity 2.8 (Table I). The most common presenting symptoms were lower abdominal pain and vaginal bleeding following a missed or scant menstrual period. The presrbnce of hemoperitoneum was confirmed by culdocentesis in 60 per cent of the patients. Ruptured ectopic pregnancy was confirmed by colpotomy in 10 per cent of the cases and by laparotomy in the remainder. Twenty-five per cent of the patients had had one or more previous abortions and four patients had had a previous ectopic pregnancy. Microscopic evidence of follicular or interstitial salpingitis was present in 42 per cent of the cases. Previous bilateral partial salpingectomy for sterilization had been performed on five patients. Eighty-one patients were treated by means of unilateral salpingectomy (36 ol’ tht:sc also had unilateral oophorectomy ) . and 15 by hysterectomy with salpingectomy (four also had unilateral oophorectomy) (Table II). The average volume of intraperitoneal blood present prior to operation was 375 ml.
RUPTURED
Methods
and
results
From 1964 to 1971, 96 patients with ruptured tubal pregnancy were treated at the University of Kentucky Medical Center and affiliated hospitals. During the same time period, there were 22,428 live births-an
From the Department Gynecology, University Medical Center. Received
for
Accepted
October
*Junior American
of Obstetrics of Kentucky
publication
July
and
31, 1972.
2, 1972.
Faculty Clinical Fellow, Cancer Society. 995
996
Table
Harralson,
van
Nagell,
and
I. Basic characteristics
Roddick
of group
Table IV. Morbidity function of operative
and hospital procedure
stay as a
Operation
Salpingectomy or salpingo-oophorectomy Hysterectomy with salpingectomy or salpingo-oophorectomy Total
Table II. Type tubal pregnancy
81
26.5
15 G
2.8
-29.9 27.0
of operation
-2.8 2.8
Table
for ruptured
45 36
46.9 37.5
15
15.6 100
ss
Table
III.
Findings
at operation Pelvic infiammatory disease (%)
Salpingectomy or salpingo-oophorectomy Hysterectomy with salpingectomy or salpingo-oophorectomy Total
V. Postoperative
33
6.2
33
7.0
25
6.3
morbidity
Morbidity ~~- 1:~~;z?;
Patients IX-T-T-
Unilateral salpingectomy Unilateral salpingo-oophorectomy Hysterectomy with salpingectomy or salpingo-oophorectomy
Salpingectomy or salpingooophorectomy Hysterectomy with salpingectomy or salpingooophorectomy Total
Zntraperitoneal preoperative blood loss (ml.1
38
815
62
375
-Ti
746
Urinary tract infection Pneumonia, atelectasis Wound infection Pelvic cellulitis Peritonitis Total
2
13.2
8
9.8
0
0
6
7.4
1
6.7
2
2.5
6.7 - 6.7 33.3
3 -0 19/81
1 -1 5/15
3.7 __0 23.4
lowing unilateral salpingectomy of pulmonary failure secondary to intraoperative aspiration pneumonitis. Comment
in the hysterectomy group and 815 ml. in the salpingectomy group (Table III). Blood loss directly attributable to operation was 290 ml. for hysterectomy and 150 ml. for salpingectomy or salpingo-oophorectomy. The mean postoperative febrile morbidity was higher in the hysterectomy group (Table IV), although the total number of postoperative days was increased only from 6.2 to 7.0 days. The most common causes of postoperative febrile morbidity were urinary tract infection, atelectasis, and pelvic infection (Table V) . The single death occurred in a 26-year-old primigravida who died on the fifth day fol-
The incidence of tubal pregnancy at this institution is lower than that reported in other large series, and may reflect the low incidence of pelvic inflammatory disease in the referral population. Nevertheless, microscopic observation of pelvic inflammation in 42 per cent of cases correlates closely with that reported by other investigators.5, ($ The diagnosis of ruptured ectopic pregnancy was suggested most commonly by culdocentesis. Colpotomy was performed only in those cases in which culdocentesis was equivocal. Twenty-one patients were hypotensive and had an intraperitoneal blood loss of 1,500 ml. or more. These patients were operated upon immediately after admission, without culdocentesis or colpotomy. The incidence of patients with ruptured
Operative
tubal, pregnancy following tubal ligation (4.2 per cent) is higher in this study than in previous reports. Breen,l for example, found that ectopic pregnancy was preceded by tubal ligation in less than one per cent of cases. It should be emphasized that a history of previous tubal ligation should not delay performance of the necessary diagnostic procedures to confirm the presence of ruptured tubal pregnancy. Prystowsky and Eastman7 for example, noted that ectopic pregnancies occurred in over 20 per cent of puerperal tubal ligation failures. Hysterectomy with salpingectomy is being used with increasing frequency in the treatment of ruptured ectopic pregnancy. Webster and Barclay,l” in a study of ectopic pregnancies at New Orleans Charity Hospital, reported that hysterectomy at the time of salpingectomy was performed in 10.7 per cent of patients from 1947 to 1950 and in over 42 per cent from 1959 to 1963. In general, the following conditions should exist before hysterectomy is undertaken: ( 1) the patient should have had a normal cervical cytologic smear within six months prior to operation, (2) intraperitoneal blood loss should not be excessive, and (3) the patient’s vital signs must be stable. The incidence of cervical epithelial abnormality in women of reproductive age is 15 to 20 per thousand.8 Therefore, hysterectomy without prior cervical cytologic smears may result in the removal of an occult invasive cervical carcinoma. Average
management
of ruptured
tubal
pregnancy
997
intraperitoneal blood loss prior to operation in the hysterectomy group was less than half that in the salpingectomy group (Table III). All patients had stable vital signs before hysterectomy was initiated as well as throughout the operative procedure. Indications for hysterectomy with salpingectomy include sterilization, pelvic inflammatory disease with visible destruction of both uterine tubes, previous bilateral tubal ligation or ectopic pregnancy, uterine leiomyomas, and ovarian tumors. Although operative blood loss, morbidity, and postoperative hospital stay were all slightly increased in the hysterectomy group, several advantages are apparent. Recurrent ectopic pregnancy has been reported to occur in six to 15 per cent of other series.l’ 3, lo In addition, patients with ectopic pregnancy tend to be of lower socioeconomic status, and have a higher incidence of pelvic inflammatory disease and uterine pathology requiring subsequent operative intervention.* The authors do not suggest that hysterectomy should routinely be performed in patients with ruptured tubal pregnancy. The incidence of normal pregnancy following salpingectomy is as high as 50 per cent.H Nevertheless, in the multiparous patient who has had pelvic inflammatory disease or previous tubal surgery, hysterectomy with salpingectomy may be the procedure of choice in the operative management of ruptured tubal pregnancy.
REFERENCES
1. Breen, J. L.: 1004, 1970. 2. Culton, Y., Gvnecol. 29: 3. H&pin, T.: 227, 1970. 4. Haynes, D. OBSTET.
5.
Kleiner, GYNECOL.
AM.
J. OBSTET.
GYNECOL.
106:
and van Ostrand, J.: Obstet. 279. 1967. AM.’ J. OBSTET. GYNECOL. 106:
6. 7. 8. 9.
M.,
and
Wolfe, W. M.: AM. J. GYNECOL. 106: 1044, 1970. G., and Roberts, T.: AM. J. OBSTET. 99: 21, 1967.
10.
Persaud, V.: Obstet. Gynecol. 36: 257, 1970. Prystowsky, H., and Eastman, N. J.: J. A. M. A. 158: 463, 1955. Stern, E., and Neely, P. M.: Acta Cytol. 7: 357, 1963. Timonen, S., and Nieminen, A.: Acta Obstet. Gynecol. Stand. 46: 327, 1967. Webster, H. D., and Barclay, D.: Aw. J. OBSTET. GYNECOL. 92: 23, 1965.