''Acute' ectopic pregnancy

In many parts of the world one in every 50 to 200 pregnancies is ectopic. Ninety-nine per cent of them implant somewhere along the Fallopian tube. An occasional one implants in the abdominal cavity (16.9), or in the cervix (even rarer). Trouble occurs either because the tube ruptures, or because the pregnancy aborts through the abdominal end of the tube, into the abdominal cavity. How soon there is trouble depends on where the fetus embeds. It can embed: In the distal two-thirds of the tube, sites (1) and (2) in Fig. 16-3. These are the common places for an ectopic pregnancy. Here, it may cause either: (a) An acute or subacute rupture 6 to 10 weeks after the last period. Or, (b) a tubal abortion at 8 to 14 weeks, in which the fetus aborts into the peritoneal cavity out of the free end of the tube, which is not ruptured. Instead, chronic bleeding continues slowly into the pelvis, to cause a pelvic haematoma (haematocele). (3) In the isthmus (unusual), where it ruptures at 4 to 6 weeks. (4) In the uterine part of the tube (unusual) where it ruptures early. (5) In an angle of the uterus (cornu, unusual) where it may proceed to 20 weeks (see 16.8). (6) In the body of the uterus, which is the normal place. (7) Close to the internal os, leading to placenta praevia. (8) In the cervix (rare). (9) On the ovary (rare). Or, (10) elsewhere in the abdomen (rare), where it may rupture after the end of the first trimester (16.9). If an ectopic pregnancy survives to 20 weeks without causing serious symptoms, it is probably in one of the less common sites, perhaps in an angle.

Patients with an ectopic pregnancy form two groups: (1) Those who have had a massive bleed into the abdominal cavity. These are the acute and subacute cases described below. (2) Those with little abdominal bleeding. A few of these will have a massive bleed later, but many will never lose more than a few hundred millilitres of blood into their abdominal cavities. These are the ''chronic ectopics' in Section 16.7. There are also various intermediate forms.

Symptoms start when an ectopic pregnancy grows so large that it ruptures out of the tube that contains it. The patient's periods are usually a few days to a few months late, and she may rightly think she is pregnant. Or, she may not think she is pregnant because: (1) Her tube may rupture before she has missed a period. (2) Vaginal bleeding due to the ectopic pregnancy may begin at about the time of the expected period. (3) She may have an IUD in, or be on the minipill, and assume she cannot be pregnant. If her period of amenorrhoea is short, before her symptoms start, her pregnancy is likely to be in the isthmus, and the effects of rupture worse.

An acute rupture presents as a sudden severe lower abdominal pain, with signs of hypovolaemia. Her pain and internal bleeding may be severe enough to make her vomit and faint. Her pulse rises as she starts to bleed. Her blood pressure falls and she becomes shocked. Some mild dark red or brown vaginal bleeding usually follows 24 hours after the onset of the pain, as the decidua are shed (if she has had a very severe rupture and has not been treated, she may have died from internal bleeding before this happens). A ''four quadrant tap' (66.1) confirms the presence of blood in her abdomen. The blood that remains in her circulation may not have had time to dilute, so she may not yet be anaemic. Surgery is urgent.

A subacute rupture typically presents with a history of 3 to 7 days of weakness, anaemia and abdominal swelling, usually with little pain. Her lower abdomen may be tender, with rebound tenderness and guarding, but these signs are often minimal. Blood irritating her diaphragm may cause referred pain at the tip of her shoulder. She should give a history of a small dark vaginal bleed, but you may need to question her carefully to find this. A four quadrant tap confirms the presence of blood. Treatment is fairly urgent, but transfuse her first.

A chronic ectopic pregnancy presents as a vague lower abdominal pain, that is easily confused with PID (pelvic inflammatory disease) and does not require urgent treatment[md]see Section 16.7.

The diagnosis is easy when she has bled massively into her abdominal cavity, and is either shocked or grossly anaemic. But it can be very difficult, and if there is only a little bleeding, even the expert may be misled. Remember that any woman with a menstrual irregularity (a period or more missed or periods which have been lighter than usual), combined with abdominal pain and adnexal tenderness on one side probably has an ectopic pregnancy. Anaemia, dizziness, shoulder pain, and a tender mass are all extras which encourage the diagnosis, but are not necessary for it.

Ectopic pregnancies can be fatal, so if you are in doubt do a laparotomy soon. Even if your diagnosis is wrong, and she has salpingitis or appendicitis, you have done no harm. Don't let anyone who might have an ectopic pregnancy go home[md]admit her. If you decide to observe her on the ward rather than operate immediately, you must: (1) monitor her carefully, and (2) be able to operate at very short notice. As so often, ''look and see' is better than ''wait and see'.

These are rewarding patients, because they seldom die, if you treat them correctly, even if they have bled severely. So be watchful.

DON'T FORGET ECTOPIC PREGNANCY IN A WOMAN OF CHILDBEARING AGE

ECTOPIC PREGNANCY [s8]ACUTE AND SUBACUTE EXAMINATION. Look for signs of blood loss (shock and anaemia), and for signs of bleeding into the patient's abdomen. If she has generalized tenderness (which may be mild), distension, a thrill, and shifting dullness, bleeding has been severe. Rebound tenderness and guarding are variable, and may be absent. If she has a large tender mass in her lower abdomen, bleeding has been confined there by adhesions.

Gently examine her vaginally. The important signs are pain on moving her cervix, tenderness in her posterior fornix and pouch of Douglas, and perhaps acute adnexal tenderness, which is worse on one side (highly suggestive).

CAUTION ! (1) Don't do a vigorous vaginal or bimanual examination, or an examination under anaesthesia. You may squash the ectopic and may make bleeding worse. (2) Most patients are afebrile, but some have a low fever.

HER HAEMOGLOBIN is normal to begin with, falls as her blood dilutes, and shows no change for at least 24 hours, unless she has been given intravenous fluids which will dilute her blood faster. A few days after a severe bleed it may fall to as little as 30 g/l.

THE TEST FOR ORTHOSTATIC HYPOTENSION is sensitive to much milder degrees of hypovolaemia than a change in her blood pressure, which may not fall until she is quite severely hypovolaemic. If her pulse taken when she is sitting up is more than 25 beats faster than when she is lying down, she is hypovolaemic (see 66.1).

OTHER TESTS. A raised temperature and white blood count, favour a diagnosis of appendicitis, salpingitis, or torsion of an ovarian cyst, but do not exclude an ectopic pregnancy.

PERITONEAL ASPIRATION. Culdocentesis (16-6) is not very reliable. If the diagnosis is in doubt, aspirate her peritoneum. Empty her bladder, and push a syringe attached to a large needle into one of her iliac fossae pointing towards her pelvis. If you aspirate blood which does not clot, she has internal bleeding, probably from an ectopic pregnancy. If necessary, repeat this in the other four quadrants of her abdomen (66.1). You can do this in the ward.

CAUTION ! A negative test does not exclude an ectopic pregnancy.

PREGNANCY TESTS. Routine tests become positive at 2000 iu/l HCG and are only positive in 50% of ectopic pregnancies, so they are not helpful. However, there are more sensitive pregnancy tests which become positive at 75 iu/l, and are positive in 90[nd]95 per cent of cases. A negative test of this kind is very useful.

THE DIFFERENTIAL DIAGNOSIS includes many of the causes of an acute abdomen in Section 10.2, especially PID (6.6), appendicitis (12.1), urinary tract infection, and torsion of an ovarian cyst (20.7). The degeneration of a uterine fibroid in early pregnancy can also cause acute abdominal pain, but there are no systemic signs of bleeding. Other causes of anaemia, especially hookworm anaemia.

If shock and anaemia parallel the blood that she has lost vaginally (which they do not in an ectopic pregnancy), suspect an abortion. If she has ascites and anaemia, suspect an ectopic until you have proved otherwise.

LAPAROTOMY [s7]FOR ECTOPIC PREGNANCY EQUIPMENT. A general laparotomy set, equipment for autotransfusion (16-8).

RESUSCITATION. Set up a drip immediately with saline or dextran. Take blood for grouping and cross-matching. If possible, try to replace most of the blood she has lost. Contributors differ on the value of the vacuum bottle autotransfusion method (16.10) preoperatively. Some consider it very valuable.

If she is shocked and blood is scarce, restore her blood volume with saline. After you have operated and controlled the bleeding, give her whatever compatible blood you have.

CAUTION ! Operate as soon as you have started resuscitation, especially if blood and fluids are scarce. If she is bleeding severely, you may never be able to resuscitate her until you tie the bleeding vessel; large volumes of fluids will only wash her last red cells into her abdomen.

PREPARATION. Catheterize her and leave the catheter in. One ectopic pregnancy is often followed by another, so, if she has had all the children she wants, ask her permission to tie her normal tube. However, it is common for a patient with an ectopic pregnancy to have few children and want more. One contributor dislikes asking for permission for sterilization in an acute crisis, and would only do it with a ''super-grand multip'.

ANAESTHESIA. If she is shocked, or very anaemic, follow the general precautions for anaesthesia in hypovolaemic shock (A 16.7). Give her pethidine 25 mg intravenously as premedication. (1) Ether, tracheal intubation, relaxants, and controlled ventilation. Keep anaesthesia light. Give her the minimum of ether, or use nitrous oxide and a Boyle's machine. (2) Ketamine, preferably with a relaxant (A 8.4). You do not need much muscle relaxation, and most cases can be done under ketamine alone. (3) Infiltration anaesthesia (A 6.9). Subarachnoid (spinal) anaesthesia is contraindicated!

Fig. 16-4 PINCH THE PATIENT'S BROAD LIGAMENT TO STOP HER BLEEDING. As soon as you open her abdomen and have cleared away the blood (for autotransfusion if necessary), find her burst Fallopian tube. If it is still bleeding significantly, grasp its broad ligament between your finger and thumb, so as to compress the vessels and stop bleeding.

INCISION. Make a subumbilical midline incision (9.2). There will be blood in her abdominal cavity. Put your hand into her pelvis and feel for her uterus. Find her burst Fallopian tube, and if it is still actively bleeding, grasp its broad ligament between your finger and thumb, so as to compress the vessels in it, as in Fig. 16-4.

If there is much free blood in her peritoneal cavity, ladle it out into a sterile container, and filter it through gauze as you do so. Return it to her circulation by autotransfusion (16.10). It will have the same HIV status as she has, and is therefore safer than donor blood.

Examine both her tubes to make sure that she has not got two ectopic pregnancies (rare). The other tube may contain a little blood, but this is not an indication to remove it. The fetus will probably only be about 1 cm long, so you don't usually find it. Or, you may find quite a large unruptured amniotic sac containing it.

If she has a subacute ectopic, her ruptured tube will be covered with blood clot and adherent to the surrounding structures. Free it from them with scissors or a finger.

Apply two haemostats, one from the lateral and one from the medial side, as in Fig. 16-5. Let them meet in the middle with their points in contact, so that no part of her broad ligament is unclamped. Try to preserve her ovary.

Contributors disagree about positions ''X' and ''Y' for the second clamp in Fig. 16-5. Position ''X', is easier for beginners, and preserves the fimbrial end for a possible repair later (difficult, seldom successful, and unlikely to be practical). It has the disadvantage that an ovum may be fertilized by sperm which have swum up the other tube, so that a second ectopic pregnancy may occur in the same tube. Position ''Y' avoids this.

Remove the burst part of the tube by cutting along the free side of the clamps. Put two ligatures of chromic catgut under the joints of each clamp. Tie them with a sliding knot (4.8). Leave the ends of these ligatures long, and hold them in haemostats. Make double ligatures on both sides, to make sure that no arteries are missed.

CAUTION ! (1) If you don't tie these ligatures carefully, she will bleed postoperatively. (2) If she continues to bleed when you have applied two ligatures, apply more. (3) Don't do anything else which is not essential.

Clean her peritoneal cavity thoroughly. Close her abdomen without drainage. If she has previously consented, tie her other tube.

Examine the specimen. In the middle of an ill-defined placenta and blood clot you will see the amniotic sac. If there is evidence of a hydatidiform mole (rare, 32.38), send it for histology.

POSTOPERATIVELY, monitor her urine output until she is out of danger (A 15.5). Treat her anaemia, she may need further transfusions: folic acid by mouth, or iron.

Fig. 16-5 ECTOPIC PREGNANCY. A, put clamps on either side of the patient's ruptured tube. Try to preserve its fimbrial end if you can (position ''X'). If necessary, you can put the second clamp in the position ''Y'. B, cut out the ectopic pregnancy, and put two ligatures round the clamps.

DIFFICULTIES [s7]WITH ACUTE AND SUBACUTE ECTOPIC PREGNANCIES See also Sections 16.7 (chronic ectopic pregnancy), 16.8 (angular and cervical pregnancy) and 16.9 (abdominal pregnancy).

If you CANNOT FIND THE TUBE with the ectopic in it, don't panic. Allow yourself time to scoop out blood and clots. Tip the head of the table down (the Trendelenburg position), so as to make the blood and her gut move away from her pelvis. Feel for her uterus in the midline in the hollow of her sacrum. Pull it into the wound. If it is stuck down by adhesions, tear them with traction, or cut them with scissors. Having found her uterus, feel for the affected tube. If this is stuck down by adhesions to her omentum or gut, separate them (usually not too difficult). If her tube is stuck to her broad ligament on the same side (more difficult), try to get your fingers under it and her ovary, and lift them into the wound, by scraping the tip of your fingers along the back of her broad ligament. If necessary, cut adhesions between her tube and her rectum.

If her ovary is stuck to her tube, or you have torn it as you mobilized it, remove it.

CAUTION ! Before you remove her ovary (if you have to), make sure you separate adhesions between it and her broad ligament. If you don't do this, you may clamp her broad ligament too low down, and so include her ureter.

If adhesions obscure everything, search for: (1) her uterus, or (2) her infundibulopelvic ligament (20-17). On the right this comes away from under her caecum and appendix, and on the left side from under her mesosigmoid.

The blood supply to the tube and ovary comes from: (1) the ovarian vessels in the infundibulopelvic ligament. (2) The ascending branches of the uterine vessels. If you can put a clamp across her infundibulopelvic ligament, and another one across her tube and broad ligament next to her uterus, you will interrupt the blood supply to the ectopic.

If there is a RAW AREA IN HER PERITONEUM which oozes, after you have removed her ectopic pregnancy, it will usually stop spontaneously, if there are no obviously bleeding vessels. Try compressing if firmly for 5 minutes with a warm pack. If is continues to ooze, insert a drain for 24 hours, and monitor her carefully.

If you find that she has INFLAMED TUBES with pus pouring from their fimbriated ends, she has salpingitis (6.6), not an ectopic pregnancy. Don't excise them; close her abdomen and give her antibiotics.

If she has a TUBO[nd]OVARIAN abscess (6.6), drain it.

If she has a CHRONIC PYOSALPINX, excising it will be very risky if it has stuck to her gut, but this may be possible if it is not too friable and adherent.

If you find her APPENDIX STUCK TO HER TUBE, peel it off. If you damage it, do an appendicectomy (12.1).

If there is no ectopic, and you find a BLEEDING CORPUS LUTEUM, control bleeding with sutures. If this is difficult, excise the corpus luteum from her ovary and suture the gap. Or, less satisfactorily, remove her ovary. If she is less than 8 weeks pregnant, she will probably abort. After 8 weeks the placenta makes enough progesterone to keep the pregnancy going.

If there is a SECOND PREGNANCY in her uterus (very rare), removing the ectopic pregnancy may not disturb it. If she continues to have amenorrhoea its presence will soon be obvious.

If she has a LARGE PURPLE HAEMATOMA in her broad ligament (rare), her ectopic pregnancy has ruptured into it, and not into her peritoneum, and may be quite large (12- to 16- week size or larger).

CAUTION ! (1) Don't burrow into the lower part of her broad ligament. You may damage the large venous plexuses there, or her ureter. (2) Don't try to control bleeding by suturing deeply, unless this is absolutely essential. You may tie her ureter.

Here are two ways of treating her:

First method. Clamp and divide her round ligament on the same side 2 or 3 cm from her uterus. Clamp her tube and ovarian ligament close to her uterus, but don't divide them yet (if her anatomy is confused, leave this and do it later). Cut the peritoneum from her round ligament in the direction of her infundibulopelvic ligament. This will open the top of her broad ligament. As you approach her infundibulopelvic ligament, find, clamp and divide her ovarian vessels without including her ureter! For the anatomy of her ureter and pelvic ligaments see Figs. 15-6, 20-16, and 20-17.

This will have isolated both blood supplies to her ectopic pregnancy. Now you can clamp and divide her tube and ovarian ligament. If the ectopic is not already free, a little blunt dissection should free it from the base of her broad ligament. If oozing from the base of her broad ligament does not stop spontaneously, clamp and tie the bleeding vessels.

Second method. Mobilize her uterus by removing blood clot and dividing light adhesions. Apply two large artery forceps to her tube as shown in Fig. 16-5, but don't excise the ectopic pregnancy yet.

Cut a half a centimetre opening in the back of her broad ligament, and squeeze out the haematoma by pressing it from below.

Watch her; several things can happen after either method.

If the haematoma does not reform (usual), you are lucky, the artery forceps have controlled the bleeding. Excise the ectopic pregnancy, complete the operation in the usual way, and then suture the hole in her broad ligament.

If the haematoma reforms (unusual), open her broad ligament more widely, look for a bleeding point, and tie it.

If there is no bleeding point, but only a general ooze, press a warm pack against the oozing area, and wait 10 minutes by the clock. If this controls bleeding, complete the operation.

If a pack fails to control the bleeding, tie or undersew as many bleeding vessels as you can. Be careful to feel for her ureter to avoid including it in a ligature. Trace it from where it enters her pelvis over her sacroiliac joint (20-16). It has a characteristic firm feeling, and you can roll it between your fingers.

Fig. 16-6 CULDOCENTESIS can be used to confirm the presence of blood or pus in the pelvic peritoneum, and to distinguish between PID and a pelvic heamatocele (chronic ectopic pregnancy) as the cause of a pelvic mass.