CHAPTER IV

OPERATIONS FOR EXTRA-UTERINE GESTATION

The systematic surgical treatment of extra-uterine gestation we owe to the genius of Lawson Tait. His first operation for this condition was performed in 1883. Tait wrote that he conceived and carried out this operation in obedience to the canon of surgery relating to the arrest of hæmorrhage, and which is valid in other regions of the body.

Many surgeons (even a butcher) had removed living, dead, and putrescent extra-uterine fœtuses from the abdomen of living women, but Tait was the first to attempt the operation in those early stages of tubal gestation in which the tube bursts, or expels (tubal abortion) the products of conception through the cœlomic ostium or a rent in the gestation-sac, into the abdominal cavity, accompanied by an escape of blood so abundant that it may destroy life in a few hours.

=Indications.= The operative treatment of extra-uterine gestation depends mainly on the stage at which it is required.

When a gravid tube is detected before rupture, the operation is practically that of oöphorectomy: and is simple and safe.

When the operation is required in consequence of the bursting, or abortion, of an early gravid tube, great promptness is often required on the part of the surgeon to prevent the patient dying from hæmorrhage, and although the operation in these circumstances is really an oöphorectomy, it often has to be performed in the patient’s room as an emergency operation and without the elaborate surroundings of a modern operating theatre.

There are few accidents which test the skill, nerve, and resource of a surgeon more than cœliotomy for a suspected intraperitoneal hæmorrhage from a gravid tube, and few operations are attended with such brilliant results. Surgeons are often astonished to find a large amount of blood in the pelvis due to a small perforation in a gestation-sac no bigger than a cherry (Fig. 7).

=Operation.= In removing tubes of this kind it is necessary to apply the ligature on the uterine side of the rent in cases of rupture of the tube, but when the rent involves the wall of the uterus the opening will require the application of a mattress suture for its complete closure. In some rare instances of the interstitial variety of tubal pregnancy, the uterus has been so involved that in order to effectually control the bleeding it has been found necessary to remove the uterus.

After the pedicle has been safely ligatured and the blood removed, the abdominal incision is sutured as described on p. 9. When the shock due to the bleeding and operation has been great, it is sometimes judicious to pour one or two pints of saline solution at the temperature of 102° F. direct into the abdominal cavity.

The majority of cases of internal bleeding from gravid tubes in the early stages are submitted to operation at periods varying from a few hours, days, weeks, or even months, after the primary bleeding.

When the tube bursts, the hæmorrhage may not be so profuse as to induce death; and the woman, recovering from the shock, does not manifest such grave symptoms as to demand surgical aid. The consequence is that the patient sometimes remains for several weeks under palliative treatment (unless a renewal of bleeding kills her), and at last she seeks surgical advice. Appreciation of the true nature of the case leads to operation.

In such cases, when the abdomen is opened, the free blood in the abdominal cavity is easily removed by sterilized dabs of absorbent material. The damaged tube and ovary are removed as in oöphorectomy. When there is much free blood care must be taken that no clots are left in the iliac fossæ. When the blood has remained in the belly for several weeks after rupture, it is judicious to insert a small drain for a few days. The importance of removing blood and blood-clot from the peritoneal cavity is demonstrated on p. 98.

Where a tubal pregnancy progresses beyond the third or fourth month and invades the broad ligament before giving trouble from internal bleeding, an operation may be necessary at any moment. At this period the operation consists in exposing the parts by a median subumbilical incision, and then opening the gestation-sac, turning out the fœtus, placenta, and clot, and controlling the bleeding by firmly packing the cavity with dabs. The edges of the sac are then stitched to the lower end of the wound; the upper part of the incision is closed, and the sac is drained with a rubber tube of suitable size and allowed to gradually heal.

In cases where the pregnancy continues beyond the fourth month to full time an operation may be required at any moment. Up to the fourth month it may be even possible, in some cases, to remove the embryo, placenta and gestation-sac on the same plan as an ovarian cyst. This is occasionally possible even when the gestation runs to term, but in the majority of cases, when the gestation has passed the fourth month and the fœtus is alive, the surgeon cannot expect to deal with the sac in this summary manner, (unless it be a cornual pregnancy) he has to reckon with the placenta.

In operating for the removal of a gravid tube in the early weeks, the surgeon may be exercised in his mind in regard to the opposite tube, for a careful study of the literature of this subject clearly shows that the patient is liable to conceive in the opposite tube, and in some instances this has happened within a few weeks of the removal of its fellow. The liability of a repeated tubal pregnancy may be fixed at 5 per cent. Moreover, in operating for tubal pregnancy, the opposite tube should be carefully examined, because both tubes may be gravid, though, as a rule, the pregnancies are of different dates. To spare a woman a recurrence of tubal pregnancy it has been urged that the surgeon should remove the opposite tube, but men of ripe experience and judgment are averse to such a proceeding, for it is an established fact that uterine pregnancy is not uncommon after unilateral tubal gestation. My own experience is in harmony with this. In some cases of unilateral tubal abortion the operator has cleared out the tubal mole and clot, and left the tube. This is not good practice: I think a tube which has once been pregnant should be removed. If the opposite tube is obviously diseased, and this happens in a small proportion of patients, it should be removed.

The method of dealing with the sac of an extra-uterine gestation after the fifth month depends in a great measure upon whether the fœtus is alive or dead. The gestation-sac after this date consists usually of the expanded tube closely incorporated with the tissues of the broad ligament, which may be thick in some parts and very thin in others. To the walls of the sac, coils of the intestine, and particularly the rectum, adhere. Experience decides that the safest plan, after exposing the gestation-sac through an abdominal incision, is to cut into it and remove the fœtus and placenta. When the fœtus is dead there will be little trouble from the placenta. The edges of the incision are stitched to the margin of the abdominal wound and drained.

In those rare cases where the amnion erodes the tube and invades the belly (ventral pregnancy), the gestation-sac, with its contents, has been successfully removed by merely transfixing its base with silk ligatures.

The great danger of operations for extra-uterine gestation after the fifth month, when the fœtus is alive, or only recently dead, is the furious bleeding which accompanies the detachment of the placenta. It may be stated that an operation for tubal pregnancy after the fifth month of gestation, with a quick placenta, is the most dangerous in the whole range of surgery. About two-thirds of the patients die. The greatest danger is hæmorrhage, and the other is sepsis when the placenta has been left to slough. It cannot be urged with too much force that when it is fairly evident that a woman has an extra-uterine gestation, it should be dealt with by operation without delay: and my experience of the operation leads me to believe that it is a wise plan to remove the placenta at the primary operation. Fortunately very few extra-uterine fœtuses survive to term.

In cornual pregnancy, or, as it is often termed, ‘pregnancy in the rudimentary horn of a so-called unicorn uterus,’ the removal of the uterus is often necessary; there is, however, a variety of this form of pregnancy in which the fully developed cornu may be spared, namely, that in which the rudimentary but gravid cornu is connected with it by a distinct and usually solid pedicle. Many such have been observed and very carefully described.

In nearly all varieties of tubal pregnancy the uterine tissues are sometimes so torn that it is difficult to arrest the hæmorrhage: in this case it is now and then a wise practice to remove the uterus.

=Concurrent intra- and extra-uterine pregnancy.= The operative treatment of this condition requires consideration under three headings:--

1. =Tubal and uterine pregnancy coexist, but the complication is recognized in the early stages.= In this condition the signs are those of an early tubal rupture or abortion (Fig. 7); in the majority of the reported cases operation has been undertaken with the impression that the trouble was simply due to tubal pregnancy, the intra-uterine gestation being detected, or in some cases merely inferred from the size of the uterus, in the course of the operation.

In these circumstances the operation is carried out as for a simple tubal pregnancy, care being taken to disturb the uterus as little as possible. In many instances such an operation has been followed by brilliant consequences, for the intra-uterine pregnancy has remained undisturbed and the patients have become the happy mothers of living children.

Occasionally the operation has been followed by miscarriage and other untoward results, but, speaking generally, a gravid uterus is very tolerant of interference.

2. =Uterine and extra-uterine pregnancy running concurrently to term.= (Compound pregnancy.) This may be described as the most dangerous combination to which child-bearing women are liable. In order to show what a disastrous conjunction it is to women with two ‘quick’ children--one intra- and the other extra-uterine--I have arranged some recorded cases in the table on p. 35. Fortunately this form of compound pregnancy is rare, but a rarer combination has been recorded by Menge, in which the extra-uterine fœtus occupied the ovary and ran nearly to term. When the woman came into labour, the ovarian pregnancy was regarded as an obstructing tumour, and preparations were made for performing cœliotomy. The intra-uterine child was born in the meantime. When the supposed tumour was extracted, to the surprise of all it contained a living fœtus. The mother and both children survived.

3. =Uterine pregnancy complicated with a sequestered extra-uterine fœtus.= This is a very rare condition, but some cases have been very carefully recorded (Leopold, Stonham, Worrall).

The physical signs are those of a pelvic tumour incarcerated by a gravid uterus. The nature of the swelling may be sometimes accurately inferred before operation, as in Worrall’s remarkable case. The sequestered fœtus should be removed by cœliotomy.

After the death of the fœtus the operative treatment of extra-uterine gestation is, as a rule, a simple proceeding, the fœtus and placenta can be easily and safely removed. We have no certain means of deciding when an extra-uterine fœtus is dead, nor do we know exactly how long after the death of the fœtus the placental circulation ceases, but we do know that in course of time, if the fœtus is retained, the placenta disappears, because in cases where the fœtus is in the condition known as lithopædion there is usually no placenta. When a retained extra-uterine fœtus is wholly or partially converted into adipocere, the tissues have a strong tendency to adhere to the walls of the sac. This is especially marked in connexion with the hairy scalp.

Although a sequestered extra-uterine fœtus is uncommon, yet a surgeon may stumble on one when he least expects it: these bodies may remain undisturbed in the pelvis many years, even fifty, and be only discovered in the post-mortem room, but they are always liable to be infected from the adjacent bowel or bladder; then suppuration is inevitable. In some instances the pus makes its escape at the umbilicus, and as the sinus persists the surgeon explores it, and, on laying it open, is surprised when he extracts the fœtus, sometimes entire.

This is sometimes referred to as ‘navel delivery’, and of this several examples have been recorded. In one such case a fœtus was extracted by a butcher: the woman recovered, and the account of this remarkable case ends thus: ‘She had a navel rupture, owing to the ignorance of the man in not applying a proper bandage’ (_Phil. Trans._, Abridged Edition, 1805, vol. viii, p. 517). This is a good instance of professional bias in the apportioning of blame.

Usually, when pathogenic micro-organisms gain access to the gestation-sac the fœtus decomposes, and fistulæ form, by which pus, accompanied by fragments of fœtal tissue and bones, finds an exit and affords evidence of the nature of the case. These fistulæ may open into the rectum, bladder, vagina, uterus, or some spot on the anterior abdominal wall below or near the umbilicus. The treatment is simple, and consists in dilating the sinus and extracting all the fragments. If this be thoroughly carried out the sinus quickly closes. Partial operations are useless: if but a bit of a bone remain, a troublesome sinus will persist. It is bad practice to attempt to extirpate the sac in such condition; such an operation usually terminates fatally.

In a case of old-standing lithopædion it is unusual to find any trace of the placenta. J. W. Smith operated on a woman in whom a lithopædion had caused intestinal obstruction. The fœtus had probably been retained 15-1/2 years, and the placenta was represented by a calcified encapsuled ball, with an average diameter of 6 cm.

=Results of operative treatment.= In order to afford some notion of the risks attending the surgical treatment of extra-uterine gestation, as well as to give an idea of its relative frequency in hospital practice, the following figures will serve. From 1896 to 1907, both years inclusive, 116 operations were performed for extra-uterine gestation in the Chelsea Hospital for Women. During this period all the varieties of tubal pregnancy were encountered (ampullary, isthmial, tubo-uterine), including the rare condition of a full-time living fœtus free among the intestines, and the more uncommon condition of a full-time cornual pregnancy. There were four deaths in the series, one in 1897, 1902, and two in 1905. Death in the fatal cases was attributed to pulmonary embolism, peritonitis, and in two to heart failure.

A TABLE SHOWING CASES OF CONCURRENT INTRA- AND EXTRA-UTERINE PREGNANCY (COMPOUND PREGNANCY) RUNNING TO TERM, WITH THE FATE OF THE MOTHER AND CHILDREN.

+-----------+-------+---------+--------------+--------------+ |_Recorder._|_Year._|_Fate of |_Intra-uterine|_Extra-uterine| | | | Mother._| Child._ | Child._ | +-----------+-------+---------+--------------+--------------+ |Cooke | 1863 | Died | Died | Died | |Sale | 1871 | Died | Lived | Lived | |Wilson | 1880 | Died | Died | Lived | |Galabin | 1881 | Died | Died | Died | |Franklin | 1893 | Died | Lived | Died | |Matthewson | 1894 | Lived | Lived | Killed[1] | |Ludwig | 1896 | Lived | Lived | Lived | |Allardice | 1905 | Lived | ? | Dead[2] | |Menge | 1907 | Lived | Lived | Lived | +-----------+-------+---------+--------------+--------------+

[1] This fœtus was killed by means of a stilette passed through the abdominal wall of the mother into its thorax. The patient had two subsequent confinements without difficulty. In 1898 the ‘lump’ had shrunk, but was movable and caused no difficulty. _Pacific Medical Journal_, September, 1898.

[2] Intra-uterine child born naturally at the seventh month. Extra-uterine fœtus died, set up septic changes, and was removed by cœliotomy some weeks later.

REFERENCES

LEOPOLD. Ovarialschwangerschaft mit Lithopädionbildung von 35-jähriger Dauer. _Arch. f. Gyn., 1882_, Bd. xix. 210.

MENGE. Eine reine Ovarialschwangerschaft mit bebendem Kinde. _Vide_ Fränkische Gesellschaft für Geburtshülfe and Frauenheilkunde. _Münch. med. Wochensch., 1907_, liv. 2452.

SMITH, J. W. _Jour. of Obstet. and Gyn. of the British Empire, 1908_, xiii. 180.

STONHAM, C. Lithopædion, _Trans. Path. Soc., 1887_, xxxviii. 445.

WORRALL. Ectopic Gestation complicating Normal Pregnancy. Abdominal section. Recovery. _Med. Press and Circular, 1891_, i. 296.