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A Case of Unruptured Tubal Pregnancy Continuing to Full Term.*

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A Case of Unruptured Tubal Pregnancy Continuing to Full Term.* A CASE OF UNRUPTURED TUBAL PREGNANCY CONTINUING TO FULL TERM.* By HUGH MILLER, M.B., F.R.C.S.Ed. Honorary Surgeon, Royal Northern Infirmary, Inverness. It is well known that the lodgement and growth of a fertilised ovum in a uterine tube is a not uncommon occurrence. The cause of this is far from obvious in most cases, but it is held that possible predisposing factors may be (i) some mechanical condition?inflammatory or otherwise?interfering with the passage of the ovum along the tube and into the uterus ; and (2) some anomaly in the fertilised ovum, such as early dis- appearance of the corona radiata, favouring its immediate embedding in the uterine tube. The commonest site in which the ovum may become implanted is the ampulla, the widest part of the tube ; and this is accompanied by a form of decidual reaction in the tubal mucosa similar to the decidual formation in uterine pregnancy, but a corresponding hyper- trophy of the muscle wall of the tube does not take place. It has been found that an ovum which has taken up a situation in a tube seldom lives there for more than a few weeks. The ovum either dies in the tube, becomes extruded through the abdominal ostium?a tubal abortion?or, tubal rupture takes place, due to the eroding action of the chorion and the distension by the growing ovum of the thinned-out wall of the tube. Should the pregnancy continue after either of the latter two happenings, it does so within the peritoneal cavity (the amniotic sac becoming covered by adhesions to pelvic and abdominal structures and the placenta gaining attachment to similar tissues), that is, a Secondary Abdominal Pregnancy. The ability of the uterine tube to continue to accommodate the growing ovum is by no means certain ; as a matter of fact, it only does so in extremely rare instances (Eden and Lockyer1). Williams2 and Blacker3 admit the possibility of such occurring, and the latter illustrates and describes briefly a specimen removed at operation and in addition gives references to other cases. I have come across three cases diagnosed as examples of advanced unruptured tubal pregnancy recently reported * Read at a Meeting of the Edinburgh Obstetrical Society, 12th January 1938. OBST. 29 Hugh Miller 4 in the literature. In Fink's case, the pregnant tube was removed two years after the expected date of confinement. 5 Schumann diagnosed his case before operation as one of concealed accidental haemorrhage, but on opening the abdomen the true state of affairs revealed itself, and there was no evidence of placental separation. The child was born dead although the foetal heart had been heard a short time previously. This author suggests that if the seat of placentation is in the lower wall of the gestation sac near the mesosalpinx it favours non- rupture of the tube, as elasticity of the broad ligament permits of greater hypertrophy of the tube wall, and less chance of 6 perforation by the chorionic villi. Tottenham includes a macroscopical and microscopical report on the specimen he removed at operation. Pathological Differential Diagnosis.?In considering such cases, the pathological differentiation lies between :? Primary Abdominal Pregnancy. Secondary Abdominal Pregnancy. Ovarian Pregnancy. Pregnancy in a Rudimentary Uterine Horn. 7 Sarker describes the case of a Primary Abdominal Pregnancy which he removed at operation thirteen months after the commencement of pregnancy and six months after " the patient had experienced a false labour." Both tubal fimbria in this case were free from adhesions, loops of gut were attached to the placenta, and the sac could not be removed posteriorly. An interesting and valuable contribution is made in this paper by Sarkar regarding the pre-operative diagnosis of these rare cases. He made use of hystero-salpingography and demonstrated the relation of both tubes to the gestation sac. The lipiodol passed easily through both tubes and the shadow showed no distortion. Forty-eight hours later, oil was shown to be lying in the Pouch of Douglas between coils of bowel, while it had drained completely away from the tubes and uterine cavity. Before confirming a diagnosis of primary abdominal pregnancy both tubes should be examined in detail microscopically to exclude evidence of a previous rupture. The tube heals rapidly after such complete extrusion of an ovum, and will show no evidence of rupture to the naked eye. It is further essential that neither tubes nor ovaries take any part in the formation of the gestation sac. 3o A Case of Unruptured Tubal Pregnancy Examples of Secondary Abdominal Pregnancy advancing to a late stage of gestation have been described within recent 8 years. Hoskings' case was dealt with at the 254th day of gestation. Here the cord passed from the large gestation sac containing the foetus, through a rent in the ampulla of the tube, and became attached to the placenta which was embedded in the lateral end of the tube. Steel 9 brings out another point which is helpful in the diagnosis of this variety of abdominal pregnancy. When he reviewed in retrospect the history of his case, a diagnosis of tubal rupture in the early weeks of pregnancy was suggested, and he feels this might have been made at that time. If the primary rupture of the tube results in the ovum becoming intraligamentous and it survives, the placenta is found to lie above the foetus, whereas if the rupture is intra-abdominal, the placenta develops inferiorly. Two cases of Ovarian Pregnancy advancing to term have 10 been accepted as genuine. One was described by Gottshalk and the other by Ludwig.11 Spiegelberg's 12 four conditions should be fulfilled before a diagnosis of such is made. These are:?1. The absence of the ovary in question. 2. The presence of well-marked ovarian structures in the gestation sac wall. 3. The connection of the latter with the uterus by means of the ovarian ligament. 4. The tube plays no part in the formation of the sac, and its anatomical relations to the sac are the same as in a case of ovarian cyst. The specimen to be described fulfils none of these essential data. Specimens of advanced Pregnancy in a Rudimentary Uterine Horn have been described within recent years to this Society by Fahmy 13 and Sturrock.14 These specimens showed that healthy uterine appendages were present on the side involved and were attached to the lateral aspect of the gravid horn, the insertions of the tube, ligament of the ovary and the round ligament being in close opposition to each other. Further, there were no adhesions of the sac to adjacent viscera. A review of these varieties of ectopic pregnancy advancing to a late stage of gestation is of help when examining and attempting to classify the following case. I have recently had a patient under my care who had a tubal pregnancy of forty weeks' duration, and an account of this case is given, in the belief that the details of a condition of such rarity may be of value. 3i Hugh Miller History of a Case of Unruptured Tubal Pregnancy. The patient is aged 23 years, of good physical development, and unmarried. Menstruation commenced when she was 13, and she had regular periods every twenty-eight days and lasting five days. Six years ago she had a normal pregnancy which ended after a labour lasting three days in the delivery of a healthy female child weighing ten pounds, and there is no history of her having pelvic inflammation or venereal disease then or at any other time. She was working in London in 1936 and became pregnant, the date of the first day of the last menstrual period being 14th September. At the end of November she went to someone to have abortion procured, and an " " " operation was done on two occasions, but these were not " " successful." She was then taken to a doctor who carried out a similar procedure, and following this she had some vaginal bleeding each day for three weeks. About this time she started to have pain in her abdomen, especially on the right side, and sometimes going to the right shoulder. This pain persisted throughout the greater part of the subsequent nine months. She also had vomiting and suffered from dysuria and increased frequency of micturition. She never felt well, had fainting attacks, and spent most of the time in bed. Swelling of the abdomen was noticed in January 1937, and this continued to " " enlarge uniformly. She began to feel movements of the child in March, and these were more marked on the left side of her abdomen. An X-ray examination was made on 6th May, and this showed the presence of the foetus in the longitudinal lie, the breech presenting and the back to the left; the X-ray film did not suggest any abnormality. The foetal heart sounds were heard on 8th May. According to the date of her last menstruation, labour was expected about 21st June, and on that very day she commenced to have pain in the back and across the abdomen, which came on at regular intervals of about half-an-hour and lasted about three minutes ; this continued for four days, after which a brownish vaginal discharge was seen for a week. She " had noticed, however, that for a week before this false labour," the foetal movements had stopped. The patient was admitted to hospital on the 24th June, and as the expected emptying of the uterus did not occur spontaneously, attempts to induce this by the use of quinine and pituitary extract were made on two occasions but with no effect.
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