Rupture of the sac of an ectopic gestation is far from being a rare accident. When it occurs, it is a major emergency, one in which the doctor, isolated though he may be, must act and without delay. Eighty-five per cent. of these cases operated upon recover; eighty-five per cent. of those treated by expectancy die. These figures are in themselves sufficient argument, but when we add that the gravity of the condition grows out of hemorrhage, the reason for immediate intervention must be admitted by all. Even in case the hemorrhage tends to cease spontaneously, the urgency is scarcely less pressing to prevent infection.
<Callout type="important" title="Immediate Action Required">One does not delay grave emergency operations on mere impressions or suspicions.</Callout>
The attack comes on suddenly, There are pain, shock from the peritoneal tear, and vomiting, suggestive of acute intestinal obstruction. One might also think of appendicitis or a renal calculus. There is often a bloody uterine discharge. Brickner says of the pain that it usually localized over the site of the lesion. It has no definite character; it may be cramp-like over the affected tube; it may simulate labor pains; it may be sharp and sudden. The usual symptoms of pregnancy may be present, but their absence does not argue against the extra-uterine pregnancy. We have as yet no definite data by which we differentiate between the various forms (Medical Standard). The history of the case and, finally, the signs of progressive internal hemorrhage point to the nature of the accident. The pulse grows more rapid and feeble, the temperature falls, the features are blanched, dyspnea appears, and all the symptoms of collapse.
<Callout type="warning" title="Blindly Assuming Normality">Do not assume normal pregnancy just because symptoms are absent.</Callout>
Operation.—As Lejars says, the operation is moving and dramatic, but presents no especial difficulties if one but keeps cool and knows what is to be done.
Instruments.—The instruments usually required are scalpel, scissors, artery forceps, two long clamp forceps, two retractors, and curved needles. General Anesthesia, General anesthesia is necessary and must be closely watched. A continual hypodermoclysis is an excellent means of combating the combined effects of shock and anesthesia. It should not be begun, however, until the hemorrhage has been controlled.
Antisepsis.—It is scarcely necessary to say that it is of little use to save the patient from hemorrhage to die a few days later from sepsis. The peritoneal cavity, under the conditions assumed, is a dangerous culture medium.
<Callout type="gear" title="Trendelenburg Position">The Trendelenberg position is almost indispensable and if necessary may be improvised.</Callout>
Incision.—A median incision extending from the umbilicus toward the pubes is made. Do not wound the bladder, which may be pushed upward and forward. This, however, is not particularly serious unless the wound should be overlooked. Waste no time. As soon as the peritoneum is opened, catch its edges with artery forceps and enlarge the orifice upward and downward. Do not try to sponge out the cavity. Without regarding the clots, which will roll out and which mask the viscera, plunge a hand into the pelvic cavity and locate the uterus, which is easily recognized. To one side, a thick, doughy, friable mass will be felt. Slip your fingers under it, break the adhesions, and enucleate it. This will empty the retro-uterine pouch—the exsac of Douglas. Feel with finger and thumb for the pedicle and, if possible, pull the entire mass up into the wound and clamp. If the mass is not adherent, a single clamp enclosing the broad ligament from the outer side and passing under to include the tube will suffice (Fig. 442). If there is too much adhesion, damp on either side of the pedicle. When the damps are placed, the chief end of the operation has been attained. Do not waste time trying to catch the bleeding points, but ligate en masse.
Ligate the pedicle, with a blunt, curved needle armed with No. 1 catgut, transfix the pedicle close to the cornu of the uterus, between and the forceps (Fig. 443). Ligate and then carry the ligature around the lower segment of the pedicle and tie again, directing the assistant to pull up on the clamp, after finally carrying the ligature around the entire mass and tying a third time, Preserve the ends of the ligature, Resect the tumor and lift up the stump by means of the threads to see if there is any bleeding (Fig. 444). This ligature stands between the patient and death. If two clamps have been used, it will be necessary to ligate ‘en chaine.’
Now clean out the dots, mop out the blood, and lower the pelvis to drain the upper part of the abdominal cavity. The quantity of blood is often enormous. If the patient is very weak, do not prolong the task of cleansing it all out; yet in the long run, it is better to take the time to cleanse out the fossa and wipe the intestine and omentum, for then the abdomen may be closed without drainage.
Drainage. If there is oozing, apply a gauze drain at the site of the tumor, and insert three or four drainage-tubes into different parts of the cavity to carry out the blood left behind. Do not forget to fix the drains, lest they be lost in the abdomen.
Suture the wound partially, unless able to dispense with suturing, in which case suture completely, Apply a dry dressing of gamee and absorbent cotton. Inject salt solution. After twelve hours, change the dressing, which will probably be saturated; thereafter change daily. About the seventh day the tubes may be shortened, and about the fifteenth day, or often sooner, altogether removed.
Interstitial tubal pregnancy (Fig. 443) may occasionally be met with and present complications. A case described by O. G. Pall, of Indianapolis (Western Clinical Recorder, March, 1903), illustrates the subject. On opening the abdomen a large reddish bag presented, which seemed to develop from the right wall of the uterus, involving the right tube. In order to minimize the hemorrhage as well as to secure the tumor, the upper portion of the broad ligament was clamped and another clamp placed to the left of the tumor passing obliquely across the fundus and including the uterine artery. The sac was now incised at its summit and the ileus, membranes, and placenta turned back. No ligatures were required. The sac was partially sutured, and tube fastened in its cavity and brought out through the lower angle of the abdominal wound. The drainage-tube was removed on the fifth day, and recovery was complete.
Hunt (British Medical Journal, Sept. 29, 1906) reports a similar case operated on after rupture, and the hemorrhage was only controlled after hysterectomy. In some cases, perhaps as Lejars indicates, excision of a ‘V’-shaped section from the region of the cornua with subsequent suture will succeed.
Key Takeaways
- Immediate intervention is critical for survival in cases of ruptured tubal pregnancy.
- The Trendelenberg position should be used to facilitate the operation.
- Ligation and clamping are key steps in controlling hemorrhage during surgery.
Practical Tips
- Always prioritize immediate action when dealing with suspected ectopic pregnancies, as delay can lead to severe complications.
- Be prepared for significant blood loss during these operations, and have adequate drainage tubes ready.
- Maintain a calm demeanor during the procedure to ensure precision and safety.
Warnings & Risks
- Do not assume normal pregnancy just because symptoms are absent; always consider the possibility of an ectopic gestation.
- Be cautious with anesthesia as it can exacerbate shock, so control bleeding before administering general anesthesia.
- Avoid unnecessary manipulation of the abdominal cavity to prevent further injury.
Modern Application
While the surgical techniques described in this chapter are historical and may not be directly applicable today, the principles of immediate intervention and accurate diagnosis remain crucial. Modern medical practices have improved with better diagnostic tools and safer anesthetic methods, but recognizing the signs of a ruptured tubal pregnancy is still vital for survival.
Frequently Asked Questions
Q: What are the key signs to look for in diagnosing a ruptured tubal pregnancy?
Key signs include sudden pain localized over the site of the lesion, shock from peritoneal tear, vomiting, and a bloody uterine discharge. The absence of typical pregnancy symptoms does not rule out an ectopic gestation.
Q: Why is the Trendelenberg position important during this surgery?
The Trendelenberg position helps to drain blood from the upper abdomen, making it easier to locate and manage the bleeding source in the pelvic cavity.
Q: What are the potential complications of not treating a ruptured tubal pregnancy immediately?
Without immediate treatment, severe hemorrhage can lead to shock, organ failure, and death. Immediate intervention is crucial to prevent these life-threatening complications.