Ectopic pregnancy

“ In that spirit we may now consider the cases that occur in ectopic gestation.
Case I. A surgeon is called in to treat a woman and he finds her in a state of collapse. He makes a diagnosis of tubal pregnancy, which has gone on to rupture with hemorrhage, and the bleeding will evidently be fatal to the mother unless it is checked. Practically the only chance of saving the {23} mother's life is coeliotomy and the ligation of her open arteries. Dr. Howard Kelly (Operative Gynaecology, vol. ii. p. 437) says: "When the hemorrhage is sudden and excessive the patient falls in collapse ”

“ Sometimes the embryo, instead of developing in the uterus, remains in one of the ovaries, or gets lodged in one of the Fallopian tubes, or is precipitated into the abdomen, resulting, in any of these cases, in an ectopic, or extra-uterine gestation. This almost invariably brings on the death of the fœtus, and is besides often fraught with serious danger to the mother. Even if an ectopic child should live to maturity, it cannot be born by the natural channel; but, once it has become viable, it may be saved by a surgical operation. Most commonly the embryo develops in the uterus ”

“ Over 20% of women with eclampsia die and statistics show that 10% of such cases developed in the maternities. For the child the chances are not good, nearly one half of the children dying as a result, that is, due to: prematurity, toxemia, asphyxiation by repeated convulsions of the mother, drugs administered to the mother, and injuries sustained during birth, especially forced delivery. Eclampsia is more easily developed in a pregnant woman because the kidneys are carrying an increased burden, and too often diseased through the pregnancy changes. ”

“ In the abortion of a comparatively healthy ovum the uterus approximates in size the period of gestation; the ovum as it descends during the pain becomes more broad, round, and tense, whilst in the case of a growth or clot the part which is forced down during a pain is more pointed at its presenting extremity than in the interval. In most cases of abortion, however, the uterus is rather smaller than it should be at the period of pregnancy at which the interruption occurs, and as the membranes are infiltrated with blood a mole formation is approximated ”

“ The signs of delivery that are well marked at the full period, the general symptoms then obtaining, the size of the uterus, ascertained by the hand and sound, lacerations of the perineum and cervix, the lochia, the state of the breasts, abdomen, vagina, and vulva, all of little value except in conjunction with each other, are proportionately less defined as we go back, until near the commencement of pregnancy it becomes impossible to distinguish the abortion from severe hemorrhage or from menorrhagia, unless by detecting the impregnated ovum. ”

“ When conception does occur, abortion follows with relative frequency. The reason why is not clear. The chronic endometritis may interfere with the development of the decidua; the parenchyma may not be able to undergo evolution. When pregnancy reaches its normal termination, labor is not materially influenced by the pathological condition of the uterus, but complications are liable to occur during the puerperium. Postpartum hemorrhages which do not readily yield to ergot are observed as the result of the deficiency in muscular elements. ”

“ Physical shocks, such as falls, blows upon the abdomen, jumping, tripping over carpets, jars, jolting or overexertion, may be the exciting cause of an abortion where there is a marked irritability of the uterine muscles. This factor is largely influenced by individual stability, however, as a slight jar will cause an abortion in one woman, and violent experiences will have no effect upon another, at the same stage of pregnancy. ”

“ In early gestation, the gelatinous ovum is sometimes excluded several days before the membranes; in other cases,{367} there is a discharge of serum days and weeks before miscarriage. Abortion is usually preceded by nausea, pain in the back and loins, frequent micturition, tenesmus, discharge from the womb of water or of blood. If not in their immediate, yet in their future consequences, miscarriages are much more fatal to puerperal women than appears in the registers.
Floodings are seldom fatal to women before the two or three last months of pregnancy ”

“ Although there can be no doubt that the routine correction of uterine displacements shortly after labor would go far toward restricting the occurrence of subsequent miscarriage, it would be incorrect to leave the impression that miscarriage will always occur if the uterus is out of its normal position. Not infrequently the changes wrought by pregnancy will cause the uterus to right itself spontaneously. ”

“ Concerning the varied results of eclampsia, the opinion seems to be growing that if it develops during late pregnancy, labor 193is likely to set in and a premature child be born spontaneously; in some cases, however, for reasons already given, labor is induced, while in others the mother dies undelivered. The fetus may die, after which the convulsions practically always cease and the infant is often born later in a macerated state; or the patient may recover, go to term and give birth to a normal, healthy baby. ”

“ Some patients with defective uterine lining will have slight bleeding for a long time, possibly throughout the entire period of pregnancy, because a small area of the placenta has separated, leaving, however, a sufficiently large attached area to nourish the fetus. Such women should, of course, be under a doctor’s care and sedulously avoid all shocks to the uterine musculature, for the separated area may very easily be increased to such a size 170that the fetus will be unable to secure adequate nourishment, and die as a result. ”

“ Certain abnormalities of the developing fetus are inconsistent with life, and are, therefore, a frequent cause of abortion. Dr. Mall, of Johns Hopkins University, showed after years of investigation that at least one-third of the embryos obtained from abortions were malformed and would have developed into monstrosities had they lived to term. It is often a great comfort to the expectant mother who loses her baby early in pregnancy to realize that had she carried her baby to term it might have been a monster, and that, therefore, she has not lost a beautiful, normal child. ”

“ In fact, only-child-sterility is observed chiefly after difficult deliveries, followed by long enduring inflammatory processes of the uterus and the uterine annexa, which seriously affect the woman’s reproductive capacity. It occurs especially in delicately organized, anæmic, scrofulous women, whose powers of resistance have been undermined by a single pregnancy and parturition. Finally, it is met with in women suffering from myoma uteri, a form of tumour which beyond others renders the recurrence of pregnancy difficult and unlikely. ”

“ Although in the normal course of events the fertilized ovum travels down the tube and becomes attached to the uterine lining, it is possible for it to stop, and more or less completely develop at any point along the way between the Graafian follicle, from which it has been projected, and the uterus toward which it is traveling. If the fetus develops in the ovary, it is termed an ovarian pregnancy, and a tubal pregnancy if it occurs in the tube, the latter being the most frequent variety of extra-uterine pregnancy. ”

“ To sum up the normal pregnancy, we find that in the course of ten lunar months, following the fertilization of an ovum, the uterus grows from a small, flattened, pelvic organ, three inches in length, to a large, globular, muscular sac, constituting an abdominal tumor about fifteen inches long; it increases its weight thirty-two times, that is from two ounces to two pounds, while the capacity of the uterine cavity is multiplied five hundred times. Within the cavity is a child weighing about seven and a quarter pounds, surrounded by a quart or so of amniotic fluid. ”

“ The intimate relation between the breasts and the uterus manifests itself in such a variety of ways and with such force that no one doubts its existence. Thus, if a nursing mother becomes pregnant her infant is usually deprived of sufficient nourishment or suffers some digestive disturbance; if not, and the mother, ignorant of her condition, continues with the breast feeding, she may jeopardize the newly begun pregnancy. Very likely she will be warned of the fact by the signs of threatened miscarriage. ”

“ But one of the most dangerous varieties of uterine hemorrhage is that which follows the expulsion of the placenta, or its removal from the uterus by art. Sometimes the blood escapes in great quantities from the uterus immediately after the removal of the placenta, and the pulse ceases at the wrist, and consciousness is entirely lost in a few seconds. There is no symptom before labor has commenced, or during its progress, to warn you of what is about to take place. ”

“ There was no sign of a double uterus, and the patient menstruated regularly during pregnancy, being unwell three weeks before the abortion. Harley and Tanner speak of a woman of thirty-eight who never had borne twins, and who aborted a fetus of four months' gestation; serious hemorrhage accompanied the removal of the placenta, and on placing the hand in the uterine cavity an embryo of five or six weeks was found inclosed in a sac and floating in clear liquor amnii. ”

“ Uterus unicornis, when occurring alone, and not associated with other defects or errors in development, is not a cause of sterility. Women with a uterus unicornis, with or without an accessory horn, menstruate, conceive, and pass through pregnancy and parturition, in a perfectly normal manner; indeed, some women with this developmental defect have given birth to twins. The assumption that uterus unicornis predisposes to abortion does not always hold good. ”

“ 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. ”

“ If any part with which the uterus sympathizes have its action greatly increased during pregnancy, the uterus may come to suffer, and abortion be produced. Hence the accession of morbid action or inflammation in any important organ, or on a large extent of cuticular surface, may bring on miscarriage, which is one cause why smallpox often excites abortion, whilst the 67same degree of fever, unaccompanied with eruption, would not have had that effect. ”

“ Tumors in the womb, stone in the bladder, and various uterine displacements, may also create uncertainty, or cause failure, but these accidents are rarely met with, and only interfere materially at an early stage; afterwards ballotment can be practised notwithstanding them, or auscultation may be resorted to.
In short, this mode of detecting pregnancy is one of the most certain, and the most generally applicable, that we possess. ”

“ He published a paper in the American Journal of Obstetrics (1887) , entitled "Laceration of the Abdomen and Uterus in Pregnant Women," which gave nine cases of cow-horn delivery with five living children, and in 1892 another "Abdominal and Uterine Tolerance in Pregnant Women," giving eleven more cases— "a better showing for the cow horn than the knife," as he remarked.
Another valuable statistical object was collecting the fate of all the viable extrauterine children. A statistical paper on "Ectopic Gestation" involved him in an imbroglio with Lawson Tait who called him "a library surgeon." ”

“ Inflammatory disorders, such as perimetritis and the formation of exudations in the parametrium, may render the uterus unable to undergo the enlargement necessary to pregnancy. Tissue changes in the uterine musculature may likewise prevent the implantation of the ovum, or the proper development of the uterus during pregnancy. ”

“ From what we have learned in Chapter II regarding the anatomical conditions in the early days of pregnancy it is obvious that we need not be greatly surprised at the frequency of miscarriage. On the other hand, it must not be forgotten that there are many natural safeguards against accident: to mention only one, the uterus is ingeniously swung in the abdominal cavity so as to afford a large measure of protection against mechanical shock. Usually, the provisions nature has made are sufficient to resist forces from without which tend to dislodge the ovum. ”

“ In deciding whether any substance expelled from the uterus is really a fœtus or a mole, and therefore the result of conception, or the coat of the uterus, and unconnected with pregnancy, the examination of the substances expelled must be carefully made. Moles are blighted fœtuses. An examination of the woman will be necessary, though it is not easy during the early months of pregnancy, and especially in those who have borne children, to say whether abortion has taken place or not. ”

“ The entire abortion process takes place within the mother’s home, without physician oversight, potentially leading to undetected ectopic pregnancies, failure of rH factor incompatibility detection, and misdiagnosis of gestational age — all leading to severe or even fatal consequences. ”