CHAPTER XIX THE DIAGNOSIS OF EXTRA-UTERINE PREGNANCY (Part 1)

CHAPTER XIX THE DIAGNOSIS OF EXTRA-UTERINE PREGNANCY Tubal pregnancy, p. 341: Frequency, p. 341. Etiology, p. 341. Pa- thology, p. 343. Uterine decidua, p. 344. Fate of the fetus, p. 344. Dis- eases of the ovum, p. 345. Ovarian pregnancy, p. 345. Symptoms and signs of extra-uterine pregnancy, p. 346: Pelvic hemat- ocele, p. 347. Multiple, combined, and repeated tubal pregnancies, p. 348. Diagnosis, p. 348: Early extra-uterine pregnancy, p. 348. Late extra- uterine pregnancy, p. 350. Differential diagnosis, p. 351 : Early extra-uterine pregnancy before rupture, p. 351. Early extra-uterine pregnancy after rupture, p. 352. Late extra-uterine pregnancy, p. 353. DEFINITIONS By extra-uterine pregnancy we understand the development of a fertilized ovum at some point between the Graafian follicle in which it originates and the uterus. The fertilized ovum may develop on the ovary itself, ovarian pregnancy, on the fimbria ovarica, one of the fringes at the ostium abclominalc of the Fallopian tube that extends from the ostium to the ovary, so called abdominal pregnancy, or in the tube, tubal pregnancy. It is possible, and cases have been reported, of a fertile ovum developing in a tubo-ovarian cyst, the fetal sac being made up partly of tubal and partly of ovarian tissue. Such cases are spoken of as being tubo-ovarian pregnancies. When a primary tubal (ampullar) pregnancy has grown in its development into the abdom- inal cavity it is called a tubo-abdominal pregnancy, and when, at the opposite end of the tube, a pregnancy beginning in the uterine end of the isthmus (interstitial pregnancy) develops into the uterus il is referred to as tubo-uterine pregnancy. True abdominal pregnancy does not exist, the cases reported as such being those in which the growth of the fertilized ovum 340 TUBAL PREGNANCY 341 began on ovarian or tubal structure and the subsequent develop- ment was in the abdominal cavity. TUBAL PREGNANCY A vast majority of extra-uterine pregnancies are tubal, and of these the ampullar form is probably the most common, though some authors assert that the isthmial variety has the precedence. The interstitial variety is the rarest. Frequency. — It would appear that extra-uterine pregnancy is more frequent than formerly, but whether this is really so or seems Fig. 140. — Early Ampullar Extra-uterine Pregnancy. Tubal Abortion. Natural Size. (Kelly.) to be so because of better diagnosis and the more common practice of opening the abdomen, is not plain. In 1876 Parry was able to collect only 500 cases from the literature ; to-day the literature teems with them. One prominent gynecologist in this country has reported recently having seen as many as 300 cases of extra- uterine pregnancy, another 200, and a third has operated on 154 cases. Still another operator says that operations for extra-uterine pregnancy form about four per cent of all his abdominal oper- ations, and in my own experience such operations have been nearly five per cent of all my celiotomies. Etiology. — As to the causation of tubal pregnancy we are si ill 342 EXTRA-UTERINE PREGNANCY in the dark. Dr. J. Whitridge Williams (" Extra- uterine Preg- nancy," Kelly and Noble, " Gynecology and Abdominal Surgery," Vol. II., page 137), to whom I am indebted for much of the matter in this chapter, after reviewing at length the different theories which have been advanced to explain its occurrence, says of etiology: "In many instances the arrest of an ovum in a crypt resulting from follicular salpingitis, or in a diverticulum from the lumen of the tube, may afford a satisfactory explanation, Fig. 141.— Same Case as Fig. 140. The Mole and the Fetus Have Been Re- moved from the Tube. (Kelly.) though in a certain proportion of cases even the most careful history of the patient and thorough microscopic examination of the specimen will fail to reveal a tangible cause for the condition." Any woman dining the childbearing age may have extra-uterine pregnancy. It is more often observed in women who have been previously sterile or when there has been a long interval since the last pregnancy . TUBAL PREGNANCY 343 Pathology. — It appears that the ovum is embedded and the placenta is formed in the tube exactly as in the uterus. The tube wall is invaded by the fetal elements, its structures become degen- erated and in part converted into fibrin so that they offer com- paratively little resistance to the developing fetal cells. Shortly the latter are found just under the peritoneum. In a majority of cases early rupture of the tube is due to the erosion of a large blood-vessel with consequent hemorrhage and a giving way of the thin peritoneum. Tubal pregnancy may terminate by abortion into the lumen Fig. 142. — Pelvic Hematocele. of the tube, the most frequent issue; by rupture into the peritoneal cavity, both of these taking place during the first few weeks of pregnancy; or by development even to term. Rupture is more common in pregnancy in the isthmus, and abortion in ampullar pregnancy. As far as the results go it makes little difference whether early rupture takes place through the capsular membrane into the lumen of the tube or through the wall of the tube. There is a hemorrhage in either case. The ovum with its membranes is (1) 344 EXTRA-UTERINE PREGNANCY separated completely from its bed and is expelled into the lumen of the tube and perhaps through the ostium, or (2) is expelled through the tubal wall directly into the peritoneal cavity or, (3) the separation is partial, the ovum remains, and the hemorrhage continues. The last, incomplete abortions, are the most frequent. When the ovum and its envelopes are extruded at once through the ostium abdominale the hemorrhage may cease ; when, on the other hand, the separation of the ovum from the tubal wall is only partial, the ovum may increase in size because of infiltration with blood, and a tubal mole is formed. Under such conditions the hemorrhage continues as long as the mole remains in the tube and the blood trickles from the ostium and forms a pelvic he- matocele instead of free hemorrhage into the peritoneal cavity as in the case of complete abortion or tubal rupture. Tubal rupture occurs more frequently in isthmial and interstitial pregnancy than in ampullar pregnancy. In interstitial pregnancy rupture may not occur until as late as the fourth month, whereas in isthmial pregnancy rupture generally occurs within the first few weeks of pregnancy, not infrequently before the patient is conscious that she is pregnant. Rupture occurs near the placental site and is either into the peritoneal cavity or between the folds of the broad ligament. Uterine Decidua. — A decidua, very similar in structure to the decidua of uterine pregnancy, is formed in the uterus coincident with the development of the ovum in the tube, and it is cast off soon after the death of the fetus either in small pieces, or, rarely, as a complete triangular cast of the uterine cavity. (See Fig. 143.) Hemorrhage from the uterus is apt to occur when the decidua comes away, but the membrane may be passed without the patient's knowledge. If portions can be obtained for microscopic examina- tion, either from discharges or by curetting the uterus, they furnish a valuable diagnostic sign. Fate of the Fetus. — The extruded ovum is always killed and is absorbed by the peritoneum unless it is advanced beyond the third month. It is highly improbable, as thought formerly, that the placenta can be attached to other structures in the abdominal cavity, at this time. The facts go to show that attachment is primary either on the ovary or tube and that any other adhesions are due to the later stages of the development of the fetus and OVARIAN PREGNANCY 345 placenta. If the rupture is between the folds of the broad ligament, a rare happening, the fetus dies and a hematoma of the broad ligament is formed. Exceptionally when the placenta is not injured pregnancy may continue in the broad ligament or the broad ligament sac may rup- ture into the peritoneal cavity and a secondary abdominal "preg- nancy results. If the fetus has developed beyond the third month it may be mummified, consisting of an absorption of the fluid portions so that there is nothing left but shriveled skin holding together the bones of the skeleton, or, rarely, it may form a lithope- dion, a mummified fetus in which lime salts have been de- posited. Sometimes the dead fetus and its membranes sup- purate and an abscess is formed FlG> -uterine Decidua from a and Very exceptionally this fetus Case of Extra-Uterine Pregnancy. becomes converted into adipo- ( ei e •' cere, a sort of ammoniacal soap found occasionally in dead bodies. Diseases of the Ovum. — The occurrence of tubal mole has been referred to already. (See page 344.) Hydatidiform mole has been found in the tube and differs in no respect from hydatidiform mole occurring in the uterus. In this situation it is followed by chorioepithelioma just as in the uterus. In most cases of advanced tubal pregnancy there is a diminution in the amount of liquor amnii, but hydramnios has been observed. There are two cases on record of patients who had eclampsia during false labor. OVARIAN PREGNANCY J. Whitridge Williams has collected from the literature thirteen positive cases of ovarian pregnancy, in eleven of which the preg- nancy had not progressed beyond the fourth month. In addition 346 EXTRA-UTERINE PREGNANCY he classed as highly probable or probable ovarian pregnancy, twenty-two other cases. In eleven of these thirty-five cases pregnancy had progressed to full term, so that the inference is that the ovary can accommodate itself more readily than the tube to the growing fetus. Early rupture is the rule, however, Amnion Partially separated placenta. Uterine cavity. Cervix Fig. 144. — Interstitial Pregnancy. (Bumm). in ovarian pregnancy, just as in tubal pregnancy. It is possible for the ovum to be destroyed early without rupture and ovarian hematoma may result. The implantation of the ovum on, or in, the ovary does not differ from the embedding in the uterus except that a definite decidua is wanting. SYMPTOMS AND SIGNS OF EXTRA-UTERINE PREGNANCY There are no symptoms to early unruptured extra-uterine preg- nancy and its discovery is only a matter of chance. Slight pain in the ovarian region may be present. Amenorrhea may be a symptom, but cases are recorded of rupture before it was time for another menstrual period, the patient having no idea she was pregnant. Suppression of menstruation is not as frequently a SYMPTOMS AND SIGNS 347 symptom with extra- as with intra-uterine pregnancy, perhaps clue to the presence of the uterine decidua, and if rupture or abortion takes place in the tube there is hemorrhage from the uterus. Sometimes the patient thinks herself pregnant and there may be present signs in the breasts, bluish discoloration of the anterior vaginal wall and the introitus, together with enlargement of the Fallopian tube on bimanual palpation. It has been my experience that the patient has skipped one menstrual period and has some symptoms of pregnancy before the symptoms of rupture occur. These are sudden, severe, lancinating pain in the groin, bearing down, and rectal tenesmus, followed at once by faintness and sighing respiration with collapse, pallor, distention of the abdomen, a feeble rapid pulse, and subnormal temperature. Patients seldom die of this first hemorrhage, but after a few hours there is another attack of pain, followed by greater collapse, and if there is no surgical aid death may follow. No two cases are alike, one will bleed rapidly and another slowly. Further, the amount of collapse does not seem to be in direct ratio to the amount of blood which has escaped into the peritoneal cavity, for upon operation it is found sometimes that when the abdomen is full of blood the symptoms have not been severe. In other cases most alarming symptoms follow the extravasation of a small quantity of blood. Pelvic Hematocele. — If the blood has trickled out of the ostium of the tube, as in tubal abortion, or if for any reason the discharge of blood is intermittent, there will be a series of attacks of pain, perhaps a week or two apart. In these cases a pelvic hematocele is generally formed. The blood collecting in the pelvis is partly coagulated and is walled off by an organized membrane of perito- nitic exudate. Such a collection may be a solitary, or a diffuse hematocele, the former term being applied to a smaller collection of blood in the neighborhood of the Fallopian tube. Local examination shows a boggy mass, also softness of the cervix, and pain on moving it forward with the finger. Bluish discoloration of the vagina may be present. Colostrum in the breasts is an unreliable symptom. In some cases of early rupture there is a uterine discharge of a brownish color which may con- tinue for weeks. This is due to the disintegration of the decidua in the uterine cavity. 348 EXTRA-UTERINE PREGNANCY The pelvic hematocele is generally situated in the cul-cle-sac of Douglas. If the uterus happens to be retroverted and the cul- de-sac obliterated the blood may be effused in front of the uterus and in that case the hematocele will be found anteriorly. A fresh hematocele is flaccid and fluctuates; an old one is hard and may be of uneven density. If rupture does not result in death and there is no surgical interference pregnancy may continue and secondary abdominal pregnancy may follow. Then the symptoms will be those of preg- nancy, with more pain and more suffering from the fetal movements than in uterine pregnancy. False labor sets in at term with uterine contractions and pain. The fetal sac contains so few muscular fibres that it can not contract to any great extent. The false labor may last a few hours or a number of days and is followed by the death of the child. Multiple, combined, and repeated tubal pregnancies are reported in the literature. Twin tubal pregnancies occur occasionally, both embryos being in the same tube or one in each tube, and Sanger and Krusen, according to Whitridge Williams, have reported cases of triplet tubal pregnancy, all of the embryos being of the same age. Combined extra- and intra-uterine pregnancy is not very rare. Weibel in 1905 had collected 119 cases from the lit- erature. This class includes only the combined pregnancies in which the embryos were of the same age, and not the cases of uterine pregnancy occurring in the presence of the remains of an old extra-uterine pregnancy. There have been many cases on record of repeated tubal preg- nancy in the same woman, and several cases of this have fallen under my observation. DIAGNOSIS OF EXTRA-UTERINE PREGNANCY Early Extra-uterine Pregnancy The positive diagnosis of early tubal pregnancy before rupture lias been made and has been proved by operation. Such a diag- nosis is based on the symptoms and signs of early pregnancy and the presence of a lender unilateral tumor of the tube and slight enlargement of the uterus, more especially if the woman has been DIAGNOSIS 349 sterile, or a long interval has elapsed since the last pregnancy. A diagnosis under these conditions is only probable, however. Any patient presenting such a combination of symptoms and signs should be kept under continued observations until the diagnosis is made plain or an operation is performed. The death of the fetus, usually between the fourth and the ninth week of pregnancy, is signalized by the discharge of the uterine decidua and by more or less hemorrhage from the uterus. At this time the diagnosis is apt to be uterine abortion. Always carefully examine the ovaries and tubes in cases of abortion and if possible get shreds of extruded tissue for microscopic examination. In exfoliative endometritis a cast of the uterine cavity may be thrown off, and therefore the extrusion, in extra-uterine pregnancy, of the decidua in one piece, triangular in shape, is not proof positive of the existence of this disease, but may be classed as presumptive evidence. On the other hand, the cast-off decidua may be lost at an early date, perhaps without the patient's knowledge. A tubal tumor of a size corresponding to the length of time the supposed pregnancy has existed, a slightly enlarged uterus, a relaxed vagina with bluish discoloration, a vaginal discharge of blood and shreds of tissue, and pain caused by pulling the cervix forward with the finger in the vagina make the diagnosis of tubal pregnancy most probable. The symptoms of rupture have been considered under the heading of symptoms, page 347. They are characteristic. Sudden faintness and collapse, together with severe pain in the region of the pelvis in a woman who has gone over her period, make a prob- able diagnosis of rupture of an extra-uterine pregnancy. If the patient recovers quickly the probabilities are in favor of its being tubal abortion. If there are recurrent attacks and a hematocele can be made out — a boggy mass of indefinite outline — the diagno- sis of tubal abortion is undoubted. If the patient goes from bad to worse, and there are rigidity of the abdomen, increasing abdomi- nal pain, pallor, sighing respiration, subnormal temperature, and a thready pulse, the diagnosis is tubal rupture and the abdomen should be opened at once. After the first attack of collapse and pain, there is to be felt a mass in the pelvis. 350 EXTRA-UTERINE PREGNANCY Late Extra- uterine Pregnancy In the later stages of extra-uterine pregnancy a correct diagnosis is seldom made until full term is reached. In the later months of pregnancy the diagnosis rests on finding the child lying outside Fig. 145. — Unruptured Ampullar Extra-uterine Pregnancy, (Williams.) Four Months. of the uterus, which is the size of a three months' pregnancy. The child can be palpated, the fetal heart sounds heard, and fetal movement felt, if the child is alive. The