An ectopic pregnancy occasionally implants itself towards the medial end of a patient's Fallopian tube. If it implants itself at the point where her tube enters her uterus, it ruptures early, but if it implants in the intramural part of the tube near her uterine cavity (angular or cornual pregnancy), it may not rupture until 20 weeks (see Fig. 16-3). In either case the whole angle of her uterus becomes a bleeding mass. When this happens, you can usually resect part of her uterus (a wedge resection).
If an ectopic pregnancy implants itself in her cervix (a cervical pregnancy, rare) this will be open and contain a thin-walled cavity in which you can feel fragments of chorionic tissue. This cavity bleeds massively, and may resemble an abortion, but whereas there is little bleeding after an abortion has been evacuated, a cervical ectopic pregnancy continues to bleed. You are most likely to be aware of it as an abortion which continues to bleed after evacuation (16.2).
ANGULAR AND CERVICAL [s8]ECTOPIC PREGNANCIES ANGULAR PREGNANCY. At laparotomy for an ectopic pregnancy you find a purple bleeding mass arising from one angle of the patient's uterus. Bleeding can be torrential. If the only way to control it is to clamp her broad ligaments, clamp both of them and do a subtotal hysterectomy (20.12). Usually, a wedge resection is possible. Plan for Caesarean section in her next pregnancy.
CAUTION ! In some societies a woman who does not menstruate is not acceptable as a wife, and if this is so in your community, don't sacrifice her uterus unless her life is in danger.
To do a wedge resection, aim to remove the mass by cutting her uterus from around it, so as to leave a wedge-shaped gap.
If there are not too many dense adhesions between her uterus and her pelvis, tie a rubber tourniquet around the lower part of her uterus. Or ask your assistant to compress the angle as firmly as he can while you insert the sutures. Bring the two sides of the gap together firmly, and suture them with two layers of No. 2 chromic catgut, the inner layer being mattress sutures, and the outer layer simple ones (difficult, because the tissue is friable and vascular). When you have done this, you will probably find that the bleeding has stopped.
Alternatively, repair her uterus with a single layer of silk through the full thickness of its wall. Place as many sutures as necessary before you tie any. Then, as your assistant pulls all but one tight, tie the remaining one. This will minimize the risk of them cutting out.
Alternatively, remove the tube and ovary on the same side. This has the advantage of avoiding the possibility of a further ectopic pregnancy on that side.
If she already has several children, consider tying her tubes, because the risk of rupture of the scar is considerable.
CERVICAL PREGNANCY (rare). She either presents as an abortion which continues to bleed, or you may suspect that she has a cervical pregnancy, when you find a bleeding thin[nd]walled cavity in her cervix. The important differential diagnosis is an ordinary abortion which has stuck in her cervix, because her external os is too tight to let it out (16.2).
Pack the cavity tightly to stop bleeding, and let you resuscitate her. She will bleed severely.
If her ectopic pregnancy is early, packing may be all she needs. Bleeding may have stopped when you remove the pack 24 hours later.
If a pack does not control bleeding, there are two more manoeuvres you can do before hysterectomy: (1) Suture the descending cervical branches of her uterine arteries. Pull her cervix firmly down and insert catgut sutures at the 3 o'clock and 9 o'clock positions, as high as you can at the level of her cervicovaginal junction. Provided you do not go above this level her ureters will be safe. Don't do any dissection. (2) Insert a large (50 ml or more) Foley catheter into the bleeding cavity in her cervix, blow it up, and leave it for 24 hours. Fluid from her uterus will be able to drain through the tube. If this fails, ]]tie her internal iliac arteries (3.5); if this too fails do a hysterectomy (20.12).