Tubal pregnancy at term

WILLIA3lSON

:

TUBAL

PREGICANCY

AT

TERM

215

SUMMARY

Functional hypertension is a very common symptom of the menopause. This functional hypertension of the menopause in some cases develops into an organic hypertension with arteriosclerosis and chronic heart or kidney disease. From 10 to 30 per cent of cases of organic hypertension in women represent a continuation of unconSuccessful treatment of hypertentrolled menopausal hypertension. sion of the menopause will reduce the incidence of apoplexy and cardiovascular-renal disease in women. REPEREh'CES (1) xarano?l,: Ln Edad Criticx, Madrid, 1920, XXX, 204. (2) Cuzbertso?L: Surg., Banes: Am. Jour. Obst., 1919, Issix, 7. csxvi, I(%. (5) Maranon: Rev. franc. C’cmcn~dc?r, nnrl Lyle: AN. JOI-K Ossrr. quotrll ll,Y nfaElllolr.

I

T 15: difficult

exactly the number of extrauterine pregto the fact t.hat a certain number of births are not registered, and that one out of every four normal intrautertogether wit,11 a definite number of paine pregnancies miscarries, tients with extraut,erine pregnancy dyin, w of hemorrhage outside of hospital care. The figures most acceptable are those based on the vital statistics of the city of Philadelphia for the pear 1918, and the corrected standard would apparently show that, the ratio of extrauterine to normal pregnancy was 1: 303, although some clinics report a higher rate even up to an incidence of 1: 150. Comparatively few or none go to term when the rupture is intraa.bdominal. In all literature, as far as we were able to trace, there are less than three hundred cases of extrauterine pregnancies which have gone beyond the fifth month, and of this number, twelve were intraligament,ary, nine were ovarian, and only six were truly ectopic it1 the sense that they were wholly included in the tube. There are several reasons why the intraabdominal cases will not go to t,erm: the ratio of normal fetuses in the tube is only 1: 7; the type that rupt,ures into the abdominal cavity is usually ampullar and for the gestation to proceed, there must be little or no damage to the fetal sac, and of course the placenta must be firmly implanted for nourishment. Primary abdominal pregnancy, as such, does not occur and in looking over the records of the cases I was able to find only one instance where it seemed as though the placenta was wholly and primarily n;lncirs

to detwmine

1919; Abst. in Surg., Gynec. rind Obst., Gynec. nnd Obst., 1916, xxiii, 667. (3) . (4) Strassmam: Arch. f. Gynak., 1925, d’cndocrinol., 1924, ii, 408. (6) Bharlit, .WD OYXW., 192.5, s, OiG. (7) Kylin:

OCcurriIIg,

due

216

TIIE

.iMERICAS

JOURiSAL

OF

OISTETRI(‘S

attached to the liver; in all other cases peritoneal attachment was secondary to TVOU~~ seem most reasonable, for certainly original implantation ovw a short, period arable damage to the f&al blood supply, death of the fetus.

AND

GTNEC’OLOGY

the rest of the placentala pelvic attachment. This a.nv detachment from the of time mo~ild cause irrq)ant1 vonseqnently cansc the

Dr. 0. Ilad seen Ilrr for the tirst time tcu Mrs. c. \vns seen 01, April 2,s. 1927. days before, alli on occasions had ndministcwd opintes to rclicvc her of false labor pains. I-lc brliered slur had son~e sfld of :IIL :I~IIKH~II~~cwu~lition :rnd due to tllr fact that she ha11 m:tn,v cond,vIom:ls about the vulw, he thought she might have a prritoncnl infection of specific origin. IIcr obstetric Iristor~ was esncntially negative. she hat1 lI- irregular abdominal pain and occasionally was nauseated 2nd \ronlll vomit. 011 wtwucc to tile llospital she ws noted to be a l:wgc colored woman with a thick :~bdomioaI wall, resting fairly CIW~fortnbljin Iled, complaining at intcrv:lls ~rf I\-hat wcw apparentlyIabor p:cins. During a pain, there was some slight tightening of the abdominal wall, but nothing un~~swil, the fetal heart was r:lxiIv heard in the lower right :~bdominnl quadrant, :rnd the fetus seemed to be floating ill a right position wit11 no presenting part in tlw pelvis. On rectal examination no dilatation was made out. She was given morphi in order to quiet her pain, because she ~:ls making no progress. Twenty-four hours later she was still complaining of indefinite abdominal pain, hut when left :~lonc~ would promptly drop off to sleep. Since there was no change in-pulse or temperntnre, it was thought wise to wait and see whcthrr she would not spontaneously start into labor. She was rather large, and to guard against a possible multiple pregnnn~~~ an s-my was taken. The plate was not satisfactory, but the s-ray d~~p:~rtmcnt h:~zarded a guess that she might have twins. On that sclpIw3ition it xould account for the size and the general discomfort of tllc Iwtient. an11 so it was still dcw~71~~1 Forty-eight hours after hospital entwnw it ~~1s wise to wait for a normal labor. decided to induce labor, ant1 sinw slle was a multipnra, :L gauze Ijack was ins~~rtrd into the cervix and the vagina. Twelve hours later tllct patient was com1~I:~inir,g of abdomim~l pain quite continuously, tlie l)ulse had risen to 1100, and tllv patient had been vomiting; the pack was removed, and the cervix was still firm and The cervix was dilated rather hard, not at all consistent with a uterus :tt term. suficientl?+ to admit the finger and the uterus was found empt?, with the fetal 11t:~rl

Bilocular uterus or a rupt,urrtl uterus WaS the bobbing down behind the uterus. diagnosis in mind, and the patient was taken to the operating floor for abdominal section. Under ether anesthesia the abdomen was opened in midline, below the umbilicus, and a large soft mass, not at all like a uterine wall, with five small omental adhesions appeared. In attempting to steady the mass, it ruptured suddenly, and the child was precipitated among the intestines. The cord was clamped The sac was clamped, and a living child of eight pounds, four ounces, was delivered. tied, and cut off, and then the uterus came up into sight, enlarged to about three months; it was then apparent that xve had taken out the right tube. The tube and its vessels were enlarged to about the size of the thumb. ‘l’lle autopsy and the histologic section demonstrate beyond doubt that we had :I true rctopic pregnancy completely enclosed in the right tube. The patient TKIS in a bad conllition, and the abdomen lvas hastily closed with a gauze drain at the lower end of tllr wrcumd. The patient XIS put back to bed and given tllc usual trc:ttmcut for sllock c:,scs, but diecl sixteen hours after operation.

Fig.

I.-Section

showing placental corresponding

layer and to structure

loose muscular of fallopian

layer tube.

with

fibrous

tissue

AUTOPSY Peritoneal Cavity.-It contains about 200 cc. of free blood. The peritoneum is dark and injected everywhere. In Some places small fragments of greenish yellow mucoid material are found on the peritoneum. There are a good many old fibrous adhesions in the epigastrium as well as in the pelvis. The left fallopian tube is everywhere surrounded by firm fibrous bands. The right fallopian tube is missing. The diaphragm reaches the third intercostal space on the right side, and the fourth rib on the left side. Uterus.-The uterus appears moderately enlarged. The lumen contains a gauze strip. The endometrium is injected and ragged. Histologic Becord.-Specimen consists of a placenta, elliptical in shape, measuring 30 by 18 by 7 cm. with a portion of the cord and secundinae. The placenta appears to be intact. The amniotic sac is made up of two distinct membranes. The A yellowish meminterior one does not differ essentially from a normal amnion. brane about 1 mm. thick covers this amnion on the outside. This yellowish membrane can easily be pulled off the amnion; it also covers the maternal surface of the placenta, apparently forming a sac which enclosed fetus and placenta.

Microscopic Examination.-The outer pnrt of the yelloivish membrane covering the maternal surface of the placenta is made up of a thin layer of loose, vascular. fibrous, connective tissue with bundles of nonstriated muscle fibers. This structure is identical with that of the outer layers of the fallopian tube. There are accumu lxtions of blood pigment scattered through that outer roat. It is separated front the placenta by a thick layer of hyalinizcd stroma and a thick layer of fibrin and coagulated serum. The placental tissue shows not,hing significant. The histologic picture suggests a tubal p~gnancy. This diagnosis was conli~~nc~l 11.v the autopsy, which revenleil that the nlxvimen removed at operation was tlic, right fallopian tube. As one proceeds away from the maternal surface of !I!( placenta, the outer zone of thr Iyell-nourished conncctivc tissue gradually disappears, and the sac is surrounded only by a zone of l~~alinizc~rl connective tissue which evidently undergoes regressive changes. DISCUSSION

There were, as far as I could discover in the literature, out of the 2X0 extrauterine pregnancies at term, 167 living babies with a mlatrrnal mortality of 37.2 per cent. ~Since 3809, I have been able to ascwtain that nine cases recorded were wholly- contained within the tube. lteeognition of the first known case of estranterine pregnancy is attributed to Rlbucasis, an Arabian physician living in Spain, about the mitltile of the eleventh cent,ury. It is reported in Caspar Bauhin’s \tTork, (~,?~naeco?‘lcm siwe de mdierzim Affectibns ~o~mnacntwi~i, and printed ill Basle, in 158G. He recounts how he saw fetal parts escaping from >I woman’s abdomen by the simple process of suplmration. There is a question. too, as to whether the first supposedly successful eesarean srctioll by Jacob Kafer at Sigerhausen, in Switzerland, in 1500, was not an intraabdominal pregnancy, rather t,han an intrauterine. Tl1t: first definitely historical reference to surgical interference for abdominal lbregnanc,; is t.hat of Primerose,” in 1594. The first ca.se of t.rue tubal pregnancy ever published, and the first evidence of a true understanding of the condition, is fomltl in the work of Pierre Dionis”’ published in 1718. He says, “If the egg be too big, or if the diamt+r of thr tuba fallopiana is too small, the egg stops and can get no farther, but, shoots forth and takes root. thew ; am1 having the xamt~ communication with the blood vessels of t,he tuba, being capable of no such dilatation as that of the uterus breaks at last, and the fetus falls into the cavity of the abdomrn, where it sometimes lies dead for years, and at other times occasions death of mothers by breaking open its prison.” In America,, the first recorded operation for extrauterine pregnancy is by Dr. John Bard,ll of New Pork, in 1759. An abdominal tumor developed fluctuation through the lower right rectus, and on incision the suppuratin, 0. body of a full-termed fetus was deliverecl. The wound was drained and the patient made a good recovery. The first. case to be operated upon vaginally was in this country, the operation being performed by a country practitioner in South Carolina in 1816.

WILLIAMSON

:

TUBAL

PREGNANCY

AT

TERM

219

who opened the vaginal vault from below, and then, assisted by abdominal pressure and forceps, delivered the woman of a living child. The intestines herniated downwards on the third day, but the patient ultimately recovered. The first suggestion of laparotomy to check bleeding in ectopie pregnancy was made by W. W. Herbert in 1849. Parry, in 1876, urged laparotomy elocjuently, but Tait, in 1883, was the first to have the courage of his convictions and to do an abdominal section for ectopic pregnancy. His results and the ease with which they were accomplished convinced the medical world of their pra.cticability and defined the treatment in such cases. The symptomatology of the condition is confusing, for the uterus usually enlarges with the pregnancy. In a woman with a thin abdominal wall, if the fetal moT,emrnts seem very close to the hand and there is no presenting part in the pelvis, one shonlcl be suspicious of an abnormal pregnancy. There are usually some cliscomforts, due t,o adhesions of the sac, and with the slight leakage at times there is an apparent, peritoneal irritation. There may be slight contractions rrscmbling uterine contractions, the intensit,y varying with the amount of muscle tissue in the sac. The distribution of loose mnscular tissue throughout the outer layer of the sac is well shown by the microphotograph. By far the most significant symptom is that of a hard cervix, not at all consistent with a pregnancy at term. All c>xamination sl~oulcl be made under anesthesia to determine whether the uterus can be separately distinguished, and as to whether or not it is empty. Occasi,onally there will be symptoms of partial obstruction if the placenta has an intestinal attachment and much bowel is involved. The t,reatment is of course always abdominal section. The best t,ime to operate for a living baby is the thirty-eighth week, but it Troulcl seem more conservative to operate as soon as a diagnosis is made. If the mass can be removed intact, the mother has a much better prognosis than if the placenta is left behind. If the placenta cannot be removecl easily, it is better t.o leave it as it is. No drainage should be placed in the abdomen, unless the question of infection or hemorrhage arises. The pIacenta, as such, may be closed in the abclomen, and it will ultimately be absorbed. If infection occurs at a later date, that, of course, calls for a second operation. The most favorable outcome is where the mass is attached to a pedicle, which may be easily removed, or where a hysterectomy can be carried out without drainage. Beck’s work and review up to 1919 shows that the results for the mother are better when the placenta is left intact, and the abdomen is closed, rather than draining or packing, if the whole mass cannot be removed. The common causes of maternal death are, as would be expected, hemorrhage, sepsis, embolus, and pneumonia..

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AMERICAS

JOURNAL

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OBSTETRICS

AND

GYNECOLOGY

REFERENC’ES

Publication 221, Carnegie Institution, 1915, p. 104. (2) KelZy: Operative Gynecology, 1898, New York, D. Appleton and Co., ii, 458. (3) Sitt~~r: Arch. f. GynHk., 1907, liv, 526. (4) Ayers, E. A.: Obstetrics, 1899, v, 57. (5) Delcamp : Grossesse Ectopique avec’ infant vivant, Paris, 1918. (6) Horsley : Surg., Gynec. and Obst., 1913, xvi, 767. (7) Reel;, ,4. C.: Jour. Am. Med. Assn., 1919, Ixxiii, 963. (8) &r&r, J. Iv.: West Virginia Med. Jour., 1923, csvii, 465. (9) Pr;merose, J. : De Mulierum Morbis et Sjvmptomatis Libri Qartus, 1594, iv. 316. (10) Dimis, P.: Trait6 g&&al des accouchemens, Paris, 1718, p. 91. (A General Treatise on Midwifery, translated by Bell, et al., London, 1719.) (11) Bard, J.: Medical Observations and Inquiries, London, 1761, ii, 36. (1)

805

Md:

HIGIIWXD

BLDG.

A CWMl3lKED PESSARY FOR, NOXOPERATIVE PALLIATIVE: CORRECTTON OE’ CITSTOCE;LlI: AND RETROVERSION HP HERM~\N F.

M.D.,

STRONGIS,

NEW

YORK

T

because of recurrent muscle HE problem of avoiding operatiou injury in subsequent childbirth and of providing a maximum amount of comfort, particularly for two classes of patients presenting t.hemselves for treatment of cystocclc and retroversion at the postprompted the in partum clinic of the r\‘ew York Lyin g-In Hospital, vcstigation which resulted in the product,ion of the pessary to be clescribed. The pessary is made in thrcr sizes, with the following dimensions: 78itlt

Ske IYn. 1 No. 3 No. 3

I,cngth 9.0 cm. 9.5 cm. 10.5 em.

1~

(pentest) 6.0 cm. 6.5 cm. 7.5 cm.

(tip

CO?lw?X Surface to cervical orifice) 4.4 cm. 4.4 cm. 4.6 (‘111.

It is macle of hard rubber and should be cleansed by scrubbing with soap and water, and kept ready for use by immersion in a solution of lysol. The large orifice is for the cervix and is designated the cervical orifice. The convex surface or hiatal bridge supports the bladder. The perforations in the convex surface are providecl to grooves to offer resistance to facilitate drainage and the transverse the sliding mucous membrane. The intermediate size (No. 2) is the one most frequently adaptab1e.l The two groups of patient,s that, seek relief in this Clinic are as follows : 1. The nursing mot,her who agrees to an operation, but in whose case it seems advisable to wait until the nursing period is over, or of

*Presented to Medicine, Jan. ‘These pessa’ies

the 25,

section 1927. am obtained

of

Gynecology fmm

am1 Cooper

Obstetrics ;tnd

Cooper,

of 23

the Cliff

New

Work

Street,

.1cadenw New

York.