TUBAL PREGNANCY.
Tubal pregnancy occurs when a fecundated ovum is developed in the
Fallopian tube.
Fecundation may take place in the Fallopian tube, because spermatozoa
may pass through the uterus and the tube into the pelvic cavity;
but unless something occurs to arrest the passage of the fertilized
ovum into the uterus, a normal uterine pregnancy will result. It is
said by Webster that predisposition to tubal pregnancy is due to a
“developmental fault, whereby there is reversion, either of structure
or reaction tendency, in the tubal mucosa to an earlier type in
mammalian evolution.”
In other words, decidual changes, following the fertilization of the
ovum, may in some women occur in the mucous membrane of the Fallopian
tubes as well as in that of the uterus. If this condition is present in
any case, and at the same time something occurs to impede the passage
of the ovum into the uterus, a tubal pregnancy may take place.
Interference with the passage of the ovum along the tube has been
attributed to a variety of causes. Chronic salpingitis is a frequent
cause. It destroys the cilia of the epithelial cells of the tubal
mucosa. It produces thickening of the tubal walls, and causes
peritoneal adhesions that impede the normal peristaltic action of the
tube.
Obstruction to the passage of the ovum may also be caused by polypi or
tumors of the tube; by tumors external to the tube pressing upon it;
by displacement and hernia of the tube; by diverticula of the tube; or
by abnormal foldings of the tubal wall. Tubal pregnancy has occurred
in tubes in which no lesions whatever could be discovered by the most
careful examination.
It seems probable that practically all pregnancies that occur outside
of the uterus originate in the Fallopian tube.
Pregnancy may occur in any part of the tube from the abdominal ostium
to the uterus.
Tubal pregnancy is said to be infundibular when gestation begins in
the infundibulum or in an accessory tube-ending. This variety has also
been called tubo-ovarian, because in time the gestation-sac may become
adherent to the ovary and be bounded by both tube and ovary.
[Illustration: FIG. 155.--Tubal pregnancy, removed before rupture. The
opening that has been cut in the tube shows the chorionic villi.]
The pregnancy is said to be ampullar when gestation begins in the
ampulla of the tube. This is the most usual seat of tubal pregnancy.
It is called interstitial when gestation begins in the interstitial
portion, or that part of the tube in immediate relationship with the
uterus.
=Changes in the Fallopian Tube.=--During the early stages of tubal
pregnancy--the first two or three months--it seems probable that a
certain amount of hypertrophy and hyperplasia of the muscular wall of
the tube takes place. The general form of the tube is spindle-shaped
(Fig. 155). There is a marked increase in the vascularity of the tube,
most pronounced in the neighborhood of the ovum. The whole tube becomes
turgid and swollen. The peritoneal margin or ring surrounding the
ostium abdominale becomes prominent, and gradually, as has already been
described under Salpingitis, projects beyond the fimbriæ, contracts,
and ultimately hermetically closes the ostium.
Inflammation of the peritoneal covering of the tube may be present.
Such inflammation may have preceded the tubal pregnancy or may have
occurred as the result of the pregnancy. It produces various tubal
adhesions and distortions, and may still more firmly close the
abdominal ostium. The changes that take place in the mucous membrane of
the tube and in the developing ovum are similar to those that occur in
the uterus in a normal pregnancy.
A variety of terminations occur in tubal pregnancy:
I. In very exceptional cases the pregnancy may continue until full
term, without rupture of the tube taking place.
II. The tube may rupture. This is by far the most usual occurrence. The
rupture may take place into the broad ligament, into the peritoneal
cavity, or, in the case of interstitial tubal pregnancy, into the
uterus.
III. Tubal abortion may occur, the ovum being discharged through the
abdominal ostium into the peritoneal cavity.
IV. The ovum may be destroyed in the tube, gestation being stopped
before rupture takes place.
Rupture of the tube is the rule in tubal pregnancy. The time of rupture
depends upon the position of the ovum in the tube. It occurs somewhat
later in the interstitial variety than when the ovum is situated in the
free portion of the tube. Rupture in interstitial pregnancy commonly
occurs before the fifth month. In the other forms of tubal pregnancy it
occurs most usually before the end of the third month. In the latter
class of cases the greatest number of ruptures occur during the second
month.
Rupture is caused by the gradual thinning of the tube from distention.
Rupture may take place suddenly, a large hole, through which the ovum
escapes, being produced; or the rupture and discharge of the ovum may
take place gradually without causing any acute symptoms.
When the rupture takes place between the layers of the broad ligament,
the hemorrhage is usually not very profuse, as it is controlled by
pressure of the structures that surround the blood. A broad-ligament
hematoma is formed. The ovum may be destroyed as a result of the
rupture, and no further lesions due to the development of gestation
will arise. The hematoma, with the ovum, may in time be absorbed; or
suppuration may occur, with the production of a pelvic abscess; or
mummification, adipoceration, or lithopedion formation may take place
in the fetus.
If the ovum is not destroyed by the rupture, it may continue to
develop in the cavity formed by the tube and the broad ligament. The
placenta may remain attached to the inner surface of the tube, or
it may contract adventitious attachments to any of the surrounding
structures--the surface of the uterus and the pelvic floor. The cavity
occupied by the ovum may continue to enlarge, by the pushing aside of
pelvic and abdominal organs, until full term is reached and spurious
labor comes on.
In some cases a secondary rupture of the gestation-sac occurs, and the
fetus is discharged into the peritoneal cavity.
When rupture of the tube into the peritoneal cavity occurs, the
danger of fatal hemorrhage is very great. The majority of women die
within forty-eight hours after this accident, unless relieved by
immediate laparotomy. There is no surrounding pressure to control
the hemorrhage, as in the case of rupture into the broad ligament.
Sometimes the escaping ovum plugs the rent in the tube, and bleeding is
checked in this way.
If the woman survive the effects of hemorrhage, she may die from
peritonitis or from suppuration of the hematocele in the peritoneal
cavity.
In exceptional cases, if the pregnancy be early, the blood and the ovum
may be absorbed by the peritoneum, and spontaneous recovery occurs.
If the woman is not destroyed by the first effects of the rupture, the
fetus, surrounded by its membranes, may escape into the peritoneal
cavity, while the placenta may remain attached to the tube and
gestation may continue. It is very doubtful whether the fetus will
continue to live if it escapes into the peritoneum free of the
membranes. There is no evidence that an early ovum may escape into the
cavity of the abdomen and develop on the peritoneum.
If the fetus does not survive, it may be absorbed by the peritoneum or
mummification may occur.
_Tubal abortion_ means the separation of the ovum from the tube-wall,
and its partial or complete discharge through the ostium abdominale
into the peritoneal cavity. The accident is accompanied by hemorrhage
into the tube and thence into the peritoneal cavity.
Tubal abortion is most likely to occur during the early weeks of
pregnancy (the first and the second months), before the abdominal
ostium has become closed.
It is probable that tubal abortion is much more frequent than is
generally supposed. According to Sutton, tubal abortion was probably
the cause of the peritoneal hematocele in many cases in which the
bleeding was attributed to other origin, as reflux of menstrual blood
from the uterus and simple hemorrhage from the tube.
In tubal abortion the loss of blood into the peritoneum may be so
great that the woman is destroyed. In other cases death results from
peritonitis and suppuration of the hematocele. And, finally, in a
good many cases the blood and ovum may be absorbed, and recovery takes
place. Sometimes, at operation, the ovum is found in the peritoneal
cavity without any blood. The blood had either been small in amount
and quickly absorbed, or there had been no escape of blood into the
peritoneum. Blood-clot is usually found in the Fallopian tube after
tubal abortion. The ostium may become closed and a hematosalpinx may
result.
[Illustration: FIG. 156.--Extra-uterine pregnancy; tubal abortion. The
bleeding is checked by a large coagulum distending and thinning out
the tube; the fimbriated opening is greatly distended, but the greater
diameter of the clot in the ampulla prevents its escape. Wall of tube
averaging 1 millimeter in thickness. Operation. Recovery, July 7, 1896.
Natural size. (Kelly. Copyright, 1898, by D. Appleton & Co.)]
[Illustration: FIG. 157.--Coagulum turned out, showing a cast of the
tube extending up into the isthmus. On its surface lies the fetus.
Natural size. (Kelly. Copyright. 1808, by D. Appleton & Co.)]
When the ovum is destroyed in the tube before rupture takes place, the
fetus and the blood may be absorbed; or mummification, adipoceration,
or lithopedion-formation may result; or suppuration may occur, with the
formation of a pyosalpinx; or, if death of the fetus happens in the
early weeks, the tube may be found closed at the ostium abdominale,
and filled with blood in which no fetus may be detected. Such cases
have been repeatedly described as hematosalpinx, the real origin of the
condition in pregnancy not being known. The fetus had been absorbed or
broken up and scattered through the blood-mass. Careful microscopic
examination of the tube reveals the true condition--a destroyed tubal
pregnancy with hemorrhage into the tube. As has already been said,
hematosalpinx not caused by tubal pregnancy is very rare.
Coincidently with the development of the tubal pregnancy there occur
enlargement of the body of the uterus and decidual transformation
of the endometrium. The decidual membrane separates, entire or in
fragments, and is discharged from the uterus, after the death of the
embryo or during its development, from the eighth to the tenth week.
The decidua again forms only when gestation continues undisturbed.
The enlargement of the uterus varies a great deal according to the
position of the tubal pregnancy and the course of its development.
The interstitial variety is accompanied by the greatest uterine
enlargement. When the tubal gestation has reached full time the uterus
may measure from 4 to 7½ inches in length.
The increased size of the uterus is most marked in the long diameter.
The change of shape does not resemble that which occurs in normal
pregnancy.
The uterus also becomes softer in tubal pregnancy, and the cervix
softens somewhat, though not so much as in a uterine pregnancy.
If the woman and the fetus survive the many dangers that accompany the
progress of tubal gestation, the development of the fetus will go on to
full term, and then the phenomenon of spurious labor will come on.
In spurious labor there are a series of periodical pains that resemble
those of normal labor. The pains may last from a few hours to several
days. They may cease, and reappear after varying intervals.
Hemorrhage usually takes place from the uterus. After the spurious
labor the uterine discharge may be of the same character as that seen
after normal labor.
It is probable that the fetus always dies after spurious labor. The
liquor amnii is absorbed, the gestation-sac shrinks, and changes
take place in the fetus similar to those already referred to. It
may become mummified or converted into adipocere or a lithopedion.
In this condition it may remain in the abdomen for many years. A
mummified fetus that had been carried for fifty years has been removed
post-mortem from a woman aged eighty-two.
Rarely, after spurious labor the gestation-sac ruptures and the fetus
is discharged into the peritoneum, the vagina, or the large intestine,
whence it is born through the anus.
The =symptoms= of tubal pregnancy are in some cases similar in all
respects to those of normal uterine pregnancy. In extremely rare cases
the woman has reached full term in ignorance of any unusual condition.
Usually, however, the early occurrence of some of the accidents of
tubal gestation attracts her attention. Before such accidents or
complications arise there are most frequently no subjective symptoms to
excite any suspicion of the peculiar form of pregnancy. Changes in the
skin, in the nipples, in the nervous and circulatory systems, and in
the gastro-intestinal tract may resemble those of normal pregnancy, and
are subject to the same variations.
Mammary changes accompanied by the secretion of milk occur in tubal
pregnancy. These changes are, however, less pronounced than in
uterine gestation. The vagina may undergo changes similar to those of
normal pregnancy; it becomes soft, relaxed, and altered in color, and
pulsation of vessels may be felt in the walls.
It should always be remembered, however, that tubal pregnancy may occur
without the presence of any of the signs of pregnancy. Women in perfect
health, thoughtless of pregnancy, have died of acute hemorrhage from a
ruptured tubal gestation--the first symptom of this condition.
The changes in menstruation vary a great deal. Menstruation usually
ceases when tubal pregnancy begins, though not with the same regularity
as in normal pregnancy.
Sometimes menstruation continues for a few months and then ceases. In
other cases menstruation is arrested for the first few months, and
occurs with greater or less regularity during the latter months of
pregnancy. There may be an irregular discharge of blood throughout the
whole course of gestation.
In the blood discharged from the uterus there may often be found
pieces of decidual tissue of various size. Sometimes the whole
decidual membrane of the uterus may be expelled in one mass. In any
suspected case the blood should always be carefully examined for such
decidual membrane. All shreds of tissue should be submitted to careful
microscopic examination. The woman should be questioned in regard to
the passage of such tissue before she came under medical supervision.
The woman often complains of periodical pains occurring in the
hypogastrium and in the pregnant tube. They usually appear after the
second month, though they may begin earlier. These pains are thought to
be caused by the contractions of the uterus and the gestation-sac.
The abdominal enlargement in extra-uterine pregnancy differs in several
respects from that of normal pregnancy. It is usually most marked on
one side of the abdomen, especially during the first five or six months.
Toward the end of gestation the enlargement becomes more symmetrical in
the abdomen, and resembles closely that of normal pregnancy.
In tubal gestation, on account of the higher position of the tube,
bulging of the abdominal wall is likely to appear somewhat earlier than
in normal pregnancy. The abdominal enlargement in tubal pregnancy does
not follow the same uniform progress that is characteristic of uterine
pregnancy.
Fetal movements take place, and fetal heart-sounds are heard as in
normal pregnancy.
Bimanual examination made before rupture of the tube will reveal the
tubal enlargement, the shape of the tube depending, of course, upon
the position of the tubal pregnancy. The tubal enlargement is said by
Veit to have a characteristic soft feel, distinct from the hard or
fluctuating enlargements of other forms of tubal disease.
After rupture the distinct tubal tumor disappears, and the examiner
feels a mass lying to one side of or behind the uterus. The enlarged
tube may be felt merged in this mass.
If pregnancy continues after rupture, the fetal movements may be felt
and ballottement may be obtained. The cervix is found to be somewhat
softened; the os may be patulous; the uterus is soft and enlarged. The
uterine enlargement, however, is not of the same rounded shape as the
pregnant uterus, and the size is much less than that of corresponding
periods of normal pregnancy.
It is of great importance to study the symptoms of the accidents of
tubal pregnancy. As has already been said, it is usually the accident
of rupture that first directs the woman’s attention to the abnormal
condition.
The symptoms depend upon the seat of rupture. Rupture of the tube into
the broad ligament is a much less serious accident than rupture into
the peritoneal cavity.
If the rupture into the broad ligament is sudden, the woman complains
of sudden acute pain in the affected side. The pain may extend to
the back and throughout the pelvis. The intensity and extent of the
pain depend on the amount of blood that escapes. Sometimes only a
small hematoma is found in the broad ligament; at other times the
blood burrows around the rectum, and symptoms of pressure may arise.
Difficult defecation may follow. Retention of urine may occur.
The woman suffers from shock, and may become somewhat anemic.
Bimanual examination reveals the condition. The broad ligament will
be found filled with a tense mass that bulges into the vagina. The
uterus is pushed to one side. The mass may extend behind the uterus and
surround the rectum. The upper outlines felt by the abdominal hand are
ill defined.
The loss of blood from simple rupture into the broad ligament is not
often sufficient to cause death. The fetus may continue to develop,
however, and secondary rupture into the peritoneal cavity may occur.
Rupture of the tube or of the gestation-sac into the peritoneal cavity
is a very fatal occurrence. In the majority of cases death from
hemorrhage occurs within twenty-four hours.
Unless the ovum plugs the rent in the tube, there is nothing to arrest
the hemorrhage.
The woman is seized with sudden pain in the side, often described as
the sensation of “something giving away.” She suffers from faintness,
acute anemia, nausea, vomiting, and collapse. As in other cases of
acute anemia, there may be delirium and convulsions.
Bimanual examination made after intraperitoneal rupture reveals an
indefinite fulness or a yielding mass in the pelvis behind the uterus.
The blood free in the peritoneal cavity coagulates slowly, and the
fluid blood or soft unrestrained clots are often very difficult to
palpate. For this reason, at first the examiner can feel only an
ill-defined fulness in the pelvis. If the woman survives and the mass
of blood becomes more solid, it may then be distinctly palpated as a
solid mass behind the uterus, bulging into the vagina, and extending up
into the abdomen. Though the hematocele may at first be difficult to
define, yet the enlarged tube may usually be palpated, and the ovum may
sometimes be felt in the midst of the ill-defined mass of blood.
As has already been said, in rare cases rupture may occur
intraperitoneally or into the broad ligament without producing any of
the severe symptoms just described. The fetus continues to develop, and
the woman will be ignorant that rupture has ever occurred. Between the
two extremes there are all degrees of severity.
In tubal abortion the symptoms resemble those of intraperitoneal
rupture.
If the fetus dies within the tube, the symptoms become those of
hematosalpinx or other form of tubal disease.
=Diagnosis.=--The diagnosis of tubal pregnancy is not often made before
rupture, because there are usually no symptoms that direct the woman’s
attention to the abnormality of her condition. Very often she thinks
that she is normally pregnant.
If opportunity is given for examination before rupture, the diagnosis
may sometimes be made. The woman presents the signs of pregnancy. The
uterus may be slightly enlarged, though not of the size or shape normal
for the stage of pregnancy. There is a soft tubal tumor.
Immediately after rupture the diagnosis of the condition must be made
from a study of the previous history, from the present subjective
symptoms, and by bimanual examination.
If a woman who had thought herself pregnant is suddenly seized with
pain in the side, followed by anemia and shock, the suspicion of
extra-uterine pregnancy should be aroused. If bimanual examination
reveals the hematoma or hematocele in the pelvis, with tubal
enlargement, the diagnosis may be made. Pelvic hematoma and hematocele
are in nearly all cases caused by tubal pregnancy.
If the woman survives the rupture and the fetus continues to develop,
the diagnosis becomes easier the more advanced is the case.
It must be remembered that amenorrhea is not as general in tubal as
in uterine pregnancy. The woman often gives the history of irregular
bleeding, or of arrest for a few periods and then recurrence of
menstruation. Such experience may lead her to seek medical advice even
before rupture.
The intermitting attacks of pain that are sometimes felt in the
affected tube may also cause her to seek medical advice.
A history of the discharge of membrane or of shreds of membrane is
of great value. If opportunity is afforded for examination of such
shreds, and decidual cells are found, and if uterine pregnancy may be
excluded, there is very strong evidence that any mass in the pelvis is
an extra-uterine gestation.
It has been advised to curette the uterus for diagnosis in order to
determine the decidual character of the lining membrane. This is good
advice if the operation is performed with great care and if we can with
certainty exclude the possibility of uterine pregnancy. If followed
indiscriminately, numbers of abortions would be produced. Uterine
pregnancy has often been mistaken for tubal pregnancy. The mistake is
likely to occur when the fundus is drawn to one side or is retroflexed.
Uterine pregnancy may occur with tubal enlargement from other cause
than tubal pregnancy.
In conclusion, the diagnosis of tubal pregnancy before the presence of
a fetus can be ascertained is based on the following considerations:
The symptoms of pregnancy; a tubal or pelvic tumor; a slightly enlarged
though not pregnant uterus; discharge of decidual tissue from the
uterus; the history of the woman pointing to menstrual irregularity,
uterine discharge of shreds, history of previous tubal rupture.
=Treatment.=--The treatment of tubal pregnancy is operative. It may be
considered under the following heads: Before primary rupture; At the
time of rupture; After rupture.
_Before Primary Rupture._--If the physician is so fortunate as to
recognize a tubal pregnancy before primary rupture, he should without
delay remove the affected tube and the contained ovum. The operation
is simple, is attended by no more danger than that accompanying an
ordinary salpingo-oöphorectomy, and the woman is saved the imminent
dangers associated with a developing tubal pregnancy. There are no
circumstances under which it is proper to follow an expectant treatment.
Most of the cases of unruptured tubal pregnancy that have been
operated upon were not recognized until the abdomen had been opened.
The operation was performed under the diagnosis of pyosalpinx,
hematosalpinx, or some other tubal disease. The cases show the value of
the general rule to operate without delay for all gross diseases of the
tubes.
_At the Time of Rupture._--Many cases of tubal pregnancy are first seen
at the time of rupture. In such cases celiotomy should be performed
without delay. The condition is most urgent in intraperitoneal
rupture, but it is the safest rule to operate immediately, whether the
rupture be intraperitoneal or extraperitoneal. It is unwise to wait
for reaction. The physical depression in such cases is due more to
hemorrhage than to shock, and it is in accord with general surgical
principles to arrest hemorrhage at once.
Rupture usually takes place before the twelfth week, and the whole
product of conception, with the tube, may readily be removed.
Hemorrhage usually ceases as soon as the proximal and distal ends of
the ovarian artery are ligated. The ligatures may be placed about the
ovarian artery, at the pelvic wall, and at the uterine cornu, as the
first steps of the operation, before any attempt is made to remove the
mass. It may be necessary to close the rent in the broad ligament by a
series of sutures.
_After Rupture._--If the woman survive, and is first seen after primary
rupture, one of two conditions will be present--a destroyed or a
developing extra-uterine pregnancy. If the fetus has died and gestation
has ceased, the woman is exposed to the various dangers that attend the
presence of such a foreign body in the abdomen. If the fetus has died
during the earlier months, it may have been absorbed and spontaneous
cure may take place. Even a dead full-term fetus has been carried in
the abdomen for years without producing a fatal result to the mother.
It seems safest, however, in all such cases to operate as soon as the
condition is recognized. The rules of abdominal and pelvic surgery
apply to such cases. The placenta of a dead fetus may be removed
without fear of uncontrollable hemorrhage.
If the woman is seen after primary rupture, with a developing
gestation, the case presents much more serious dangers. These dangers
lie in the placenta. If the pregnancy has not advanced beyond the
fourth month, it is usually possible to remove the whole of the
gestation-sac, the embryo, and the placenta without uncontrollable
hemorrhage. The ovarian, and if necessary the uterine, arteries may be
ligated, and the placenta may be removed in one mass. The cavity of the
broad ligament may be obliterated by buried sutures.
If the gestation has advanced beyond the fourth month, it is often
impossible to remove the placenta without fatal hemorrhage. Many women
have bled to death from the attempt. The operator sometimes incises
the placenta as he enters the gestation-sac, and is obliged to proceed
with its removal. In other cases he starts to remove it, and finds, too
late, that the hemorrhage is beyond his control. In the advanced months
of pregnancy the sac and the placenta may become adherent to any of the
abdominal or pelvic viscera and to the large vessels. Hemorrhage cannot
be controlled, as in the earlier months, by ligation of the ovarian
and uterine arteries. The result in these cases is determined by the
ability of the operator. A full-term living child, the whole sac,
and the placenta have been successfully removed. If the attachments
are such that the surgeon considers it unsafe to attempt the removal
of the sac and the placenta, the sac should be incised and the fetus
should be removed, the cord being divided between two ligatures; the
sac should be sutured to the abdominal incision; the cord should be
drawn through the opening, and the sac packed with gauze. At the end of
four or five days the gauze pack may be removed, under anesthesia if
necessary, and the placenta may be taken away. There is very much less
risk of hemorrhage after the lapse of a few days. Some operators prefer
to allow the placenta to come away spontaneously. This is sometimes
necessary.
It will be seen, from this consideration, that the treatment of all
varieties of ectopic gestation is operative, and that the sooner the
operation is performed the better for the patient. Consideration for
the life of the child should have no influence in determining the time
of operation.
=Ovarian Pregnancy.=--The possibility of the implantation and
development of the fertilized ovum in the Graafian follicle has been
denied by many authorities. It seems probable, however, that such
a form of pregnancy does very rarely occur. The cause of ovarian
pregnancy is thought to be due to some disturbance of the normal
process of ovulation, whereby the ovum fails to leave the ruptured
follicle and is there fertilized and developed.