ECTOPIC GESTATION
Ectopic Gestation, called also extrauterine pregnancy, is gestation
outside the uterus in the adnexa or the peritoneal cavity. Pregnancy
in the horn of an abnormal or rudimentary uterus is classed with
ectopic gestation because the effects are similar, although pregnancy
at times in a rudimentary uterus goes on to term normally. The uterus
is in the pelvic cavity, between the bladder and the rectum, and
above the vagina, into which it opens. It is a hollow, pear-shaped,
muscular organ, somewhat flattened, and about three inches long, two
inches broad, and an inch thick. The fundus or base is upward, and
the neck is downward. Passing horizontally out from the corners or
horns of the uterus, which are at the fundus, are the two Fallopian
tubes, one on either side. These are about five inches in length
and somewhat convoluted. They are true tubes, opening into the
uterus, and they are about one-sixteenth of an inch in diameter
throughout the greater part of their extent. The ends farthest from
the uterus are fringed and funnel-shaped; and this funnel end,
called the Infundibulum or Fimbriated Extremity, opens into the
abdominal or peritoneal cavity. Near the Fimbriated Extremity of each
tube is an Ovary, an oval body about one and a half inches long by
three-quarters of an inch in width. For convenience in description,
each tube is divided into four parts: (1) the Uterine Portion, which
is that part included in the wall of the uterus itself: it extends
from the outer end of the horn into the upper angle of the uterine
cavity, and its lumen is so small that it will admit only a very fine
probe; (2) the Isthmus, or the narrow part of the tube which lies
nearest the uterus: it gradually widens into the broader part called
(3) the Ampulla; (4) the Infundibulum, or the funnel-shaped end of
the Ampulla. One of the fimbriae, the Fimbria Ovarica, is longer than
the others, and it forms a shallow gutter which extends to the ovary.
The uterus, tubes, and ovaries lie in a septum which reaches across
the pelvis from hip to hip. This septum is called the Broad Ligament.
If a man's soft hat, of the style called "Fedora," is inverted, the
fold along the crown coming up into the cavity of the hat is like the
broad ligament. As the crown is held downward the uterus would be in
the middle, its fundus upward, and outside the hat, representing the
pelvic cavity, but in the crown fold. The tubes and ovaries would
also be in the crown fold, or broad ligament, and the fimbriated
extremities would open into the interior of the pelvic cavity through
holes. The ovum breaks through the surface of the ovary into the
pelvic cavity, passes, probably on a capillary layer of fluid, into
the fimbria ovarica and thence into the infundibulum, whence it moves
along slowly into the uterus.
Ovulation and menstruation occur about the same time ordinarily, and
if the ovum produced is not fecundated it gradually shrivels and
passes off through the uterus and vagina. Fecundation of the ovum
rarely occurs in the uterus, but ordinarily in the Fallopian tube.
After fecundation the ovum is pushed on through the Fallopian tube
into the uterus in from five to seven days, where it fastens to the
wall and develops normally. Hyrtl described an ovum which appeared
to reach the uterus in three days. If from some abnormal condition
of the Fallopian tube the fecundated ovum is blocked and held in the
tube, the embryo grows where the ovum stopped, and we have a case
of Ectopic Gestation. In normal pregnancy in the uterus, the uterus
grows with the embryo, but a tube does not. In the latter condition,
when the ovum is big enough it bursts the tube or slips out through
the ampulla, causing hemorrhage or other pathological symptoms.
There are certain rare abnormalities of the uterus through imperfect
embryological development, and pregnancy in such a uterus may result
in symptoms like those of ectopic gestation. Normally the uterus and
vagina are formed by the fusion of the two Müllerian ducts. When
these ducts do not fuse perfectly, or when one develops partly, the
various kinds of abnormal wombs and vaginas are the results. There
may be a double uterus with a single or double vagina, a uterus with
a complete or partial septum down the middle, a uterus with one
horn, a uterus with a developed horn and a rudimentary horn, and the
rudimentary horn may be open or shut, and so on. In many of these
conditions the ovum becomes blocked and rupture follows as in ectopic
gestation.
When the ectopic ovum begins to develop in the Fallopian tube the
placental villi erode the tubal wall and the blood-vessels. At length
the ovum slips out of the ampulla--the common result--or the tube
bursts. The break may be traumatic in origin, from jarring or a like
accident, or it may be spontaneous. If the rupture is through the
tube there is hemorrhage into the pelvic cavity; if the ovum slips
out of the ampulla the tubal abortion causes hemorrhage as in uterine
abortion. In either case the blood with peritoneal fibrin forms a
hematocele, and this, with the ovum, may be finally absorbed; or the
woman may bleed to death unless the hemorrhage is checked surgically;
or the child may live for varying periods up to term. The tube rarely
ruptures into the fold of the broad ligament.
The fetus usually dies after rupture or tubal abortion, and if it
has not advanced beyond the eighth week it is absorbed. Sometimes
it lives. When the rupture or abortion does not tear the placental
site the fetus may develop in the abdominal cavity. Between 1889
and 1896 Haines[103] found 40 operations for ectopic gestation done
after the seventh month of pregnancy with 10 maternal deaths. Of the
children, 27 survived the operation from a few moments to fifteen
years. Sittner, in 1903, compiled from the medical reports 142 cases
of viable ectopic fetuses, and Essen found 25 additional cases. Since
Essen's article more have been reported, about 173 to my knowledge,
but the number is considerably larger.
[103] Kelly's _Operative Gynaecology_. New York, 1898.
Hirst says an experienced obstetrical specialist sees from 12 to 24
cases of ectopic pregnancy annually. Küstner himself operated on 105
cases in five years. About 78 per cent. of all ectopic gestations
result in tubal abortion and 22 per cent. in rupture.
Many specialists now are of the opinion that the diagnosis of ectopic
gestation ordinarily is not difficult, but most physicians find it
very difficult. Before rupture of the tube or a hemorrhage diagnosis
is hardly ever made by any one, and no pelvic condition gives rise
to more diagnostic errors. When there is rupture or tubal abortion
the symptoms may lead the physician to mistake the condition for
uterine abortion. In uterine abortion the onset of the symptoms is
quiet, with gradually intensifying and regular pains, resembling
labor, in the lower abdomen. In ectopic pregnancy the symptoms of a
rupture or tubal abortion arise quickly, with irregular and colicky
or very violent pains, localized on one side. In uterine abortion the
external hemorrhage is more or less profuse, with clots; in ectopic
gestation the external hemorrhage is slight or absent; the shock
in the latter case is out of proportion to the visible blood loss.
Parts of the ovum, or the presence of the whole ovum, as uterine,
are found in ordinary abortion, but in the ectopic condition the
ovum proper does not appear. An intrauterine angular pregnancy, or
pregnancy in a uterine horn, causing the upper corner of the womb to
bulge sidewise, may be mistaken for ectopic gestation. Pregnancy in a
retroflexed uterus, tumors of the adnexa, the twisted pedicle of an
ovarian tumor, a burst pyosalpinx, an appendicitis in pregnancy, or
a combined intrauterine and ectopic gestation, also may confuse the
diagnosis. When there is a dangerous hemorrhage from rupture or tubal
abortion the diagnosis is usually made without difficulty from the
collapse and other signs.
The diagnosis as to whether the fetus in the pelvis is dead or alive
may be made (1) from the absence or presence of symptoms of tubal
rupture during the second and third months, or of mild symptoms
indicating only slight bleeding; (2) from the continuation and
progress of the evidences of pregnancy, as nausea, mammary changes,
fetal movements, or audibility of the fetal heart; (3) from the
presence of a loud uterine blood souffle; (4) from the absence of
toxemia or suppuration; (5) from a growth of the uterus and a
softening of the cervix; (6) from a gradual increase in the size of
the suspected ectopic fetal tumor. In making the diagnosis great
caution must be observed, as roughness in manipulation may start
hemorrhage or rupture a thinned tube.
The diagnosis may be made: (1) that ectopic gestation exists without
symptoms of maternal hemorrhage, and the fetus is not viable; (2)
that the same maternal condition may be present, but the fetus is
viable; (3) that there may be symptoms of slight bleeding, and the
fetus is inviable; (4) that there may be symptoms of grave maternal
hemorrhage at any stage of the gestation.
The ordinary medical doctrine in the text-books is that as soon as
a diagnosis of ectopic gestation is made laparotomy should be done
and the sac with the ectopic fetus removed. If the fetus is alive
and inviable this procedure will, of course, kill it. Only a few
obstetricians of authority advise an expectant treatment. Schauta
found 75 recoveries and 166 maternal deaths in 241 cases treated
expectantly--a mortality of 69 per cent.
If there are no symptoms of maternal hemorrhage but the fetus is
evidently dead, the fetus is to be removed. If it is evidently alive,
or doubtfully alive, the treatment must be expectant. The woman is
to be removed to a hospital and kept under constant watch, day and
night, with everything prepared for immediate operation. Any woman
while bearing an ectopic fetus is in constant grave danger of death,
but the moralists hold that her danger is not so imminent before
actual rupture as to justify the death of the fetus by precautionary
removal.
In 1886 the Archbishop of Cambrai proposed the following list of
questions to the Holy Office for decision:
1. May a pregnant woman in danger of death from eclampsia or
hemorrhage be prematurely delivered of a viable child?
2. May a woman in the same condition be delivered in urgency by means
which will kill the infant?
3. May a woman _in articulo mortis_ be delivered of a viable child
if the delivery will somewhat hasten her death?
4. May the woman in question 1 be delivered of an inviable fetus?
5. May the woman in question 3 be delivered of an inviable fetus?
6. May a woman who is about to become blind, paralytic, or insane
from her pregnancy be prematurely delivered of a viable child?
7. May the woman in question 6 be delivered by means which will kill
the fetus?
8. May the woman in question 6 be delivered of an inviable child?
9. May the woman in question 6 be delivered of an inviable child,
supposing the child to be _in articulo mortis_?
10. May an ectopic fetus be killed by operation, electricity, or
poison, to avert possible danger of death from the mother?
11. May a surgeon who has opened the abdomen for some condition not
uterine incidentally remove a viable ectopic fetus?
12. With conditions like those in question 11, except that the fetus
is not viable, may the surgeon remove the inviable ectopic fetus?
Three years later, August 19, 1889, the Holy Office answered these
questions comprehensively: "In Catholic schools it may not be safely
taught that craniotomy is licit, as was decided May 28, 1884, or
any other surgical operation which directly kills the fetus or the
pregnant mother." _Safely taught_ here is a somewhat technical
expression which has been interpreted by the Holy Office in another
connection as meaning that the act is illicit morally.
The Holy Office, May 4, 1898, again decreed: "Necessitate cogente,
licitam esse laparotomiam ad extrahendos e sinu matris ectopicos
conceptus, dummodo et foetus et matris vitae, quantum fieri potest,
serio et opportune provideatur."[104] This decision was not clearly
understood, and on March 5, 1902, the same congregation reported the
following question: "Is it ever licit to remove from the maternal
pelvis an ectopic fetus which is still immature; that is, which has
not yet completed the sixth month after conception?" The answer
was, "No; according to the decree of May 4, 1898, which prescribes
that the life of the fetus and the mother must as far as possible
be carefully safeguarded. As to the time, according to the same
decree, the questioner will remember that no premature delivery is
permissible unless it is effected at such a time and by those methods
which in ordinary circumstances safeguard the life of the mother and
fetus."[105]
[104] "In a case of necessity, it is licit to do a laparotomy
for the removal of an ectopic gestation sac from the maternal
pelvis, provided the life of both fetus and mother be carefully
safeguarded."
[105] "Negative, juxta decretum 4 Maii, 1898, vi cujus, foetus et
matris vitae, quantum fieri potest serio et opportune providendum
est: quod vero tempus, juxta idem decretum, orator meminerit,
nullam partus accelerationem licitam esse, nisi perficiatur
tempore et modis, quibus ex ordinarie contingentibus, matris ac
foetus vitae consulatur."
If the fetus is removed and so killed to avert a threatened danger
to the maternal life, but not an actually operative destruction of
her life, this removal or homicide is an evil means used to avert
the danger. There is no question of a double effect, that is, of two
effects, one good and the other evil, coming with equal directness
from the cause, which is the removal or killing of the fetus; but
of a good effect, the averting of the danger to the mother, issuing
from an evil cause, the removal and death of the fetus. A good effect
does not justify the use of evil means; it is not permitted morally
_directly_ to kill the fetus, as in this case, to save the mother
from a _threatened_ grave danger.
The case is not like that of the woman who has an operable cervical
cancer while she is bearing an inviable fetus. If the cancerous
uterus is not removed the woman will surely die; if it is removed she
has a reasonable chance of cure; but if the inviable ectopic fetus
is not removed it is by no means certain that the woman will die. In
the cancer the uterus is directly removed, the fetus is indirectly
killed; in the ectopic case the fetus is directly killed, and the
danger to the woman's life is removed as a direct effect of the
killing.
Again, the killing of the inviable ectopic fetus cannot be justified
by maintaining that the fetus is an unjust aggressor against the life
of the mother. An aggressor against life may be such formally or
materially. A formally unjust aggressor consciously and voluntarily
attacks the life of the victim unjustly. This perversion, or evil, in
the aggressor's consciously actuated will sets his own right to life
in juridic inferiority to that of the victim's right to life, and the
victim may defend his own life, even unto the indirect death of the
aggressor in necessity.
The materially unjust aggressor attacks the victim's life unjustly,
but whether the aggressor is sane or insane, the attack is not
voluntary. When an insane aggressor appears to use his will, such
use lacks all moral quality because of the absence of intellect and
reason; he wills improperly, as a brute is said to will. In either
case, nevertheless, there is active aggression directed against the
victim's life, which also sets the aggressor in juridic inferiority
to the victim, and permits the victim to defend his own life to
extremes. As great an authority as De Lugo holds that in such
defence, whether the aggressor is formally or only materially such,
the victim may directly kill, but direct killing is never necessary,
as it is all a matter of intention.
The ectopic fetus cannot, of course, be a formal aggressor because it
cannot exercise either intelligence or will. It is not a materially
unjust aggressor, because the only action it is capable of is to
increase in size in obedience to the natural law of growth. It is
not trying in any manner to tear the maternal blood-vessels. It has
a right to its own life and a right to grow. Its growth may finally
bring about a maternal hemorrhage, but just now it is not causing
that hemorrhage. An aggressor is such only while there is an actual
attack going on here and now, directed against the victim's life. The
fetus is necessarily passive always, never aggressive in any sense
of the term, until the actual rupture occurs. If it may be deemed
materially aggressive when the actual rupture is taking place, the
question becomes irrelevant, because at that time the fetus may be
removed for other reasons altogether. If an insane man is in a room
with a loaded revolver which he may not use against me, but which he
probably will, I may not kill him in self-defence until he actually
begins the aggression. The opinion expressed here is the contrary of
the opinion I expressed, in 1906, in _Essays in Pastoral Medicine_.
The second condition proposed is that the ectopic gestation exists
without symptoms of maternal hemorrhage, but the child is viable. In
such a case it is probably better to remove the fetus at once, but
only a skilled abdominal surgeon should attempt the operation because
it is likely to be difficult from adhesions. A viable ectopic fetus
is usually deformed. Winckel found 50 per cent. of them deformed--the
head in 75 per cent., the pelvic end in 50 per cent., the arms in 40
per cent. Compression, infraction, hydrocephalus, and meningocele are
common. The longer the fetus is left in, the worse for the mother so
far as peritoneal adhesions and danger and difficulty in removing the
fetus are concerned.
The third case supposed that the fetus is not viable but the symptoms
of maternal hemorrhage are slight. The danger to the mother in
waiting is greater here than in case one, and the decision must be
made in keeping with evidences in the particular case. The surgeon
who assumes responsibility is obliged to remain ready for instant
operation.
Where there are symptoms of grave hemorrhage in the mother at any
stage of ectopic gestation the surgeon must operate at once, and
ligate the bleeding vessels to save the woman's life. The ligation
will shut off the blood supply to the fetus, and thus indirectly,
permissively, the fetus must be unavoidably allowed to die. This is a
clear case of double effect immediately issuing from the same cause,
and the operation is morally licit. No matter how young the fetus is,
the surgeon or an assistant is to baptize it; if it is very young it
may be necessary to split the envelopes to get at the fetus.