Preservation of Fertility by Conservative Surgery for Ectopic Pregnancy: Principles and Report of a Case

Preservation of Fertility by Conservative Surgery for Ectopic Pregnancy: Principles and Report of a Case

Preservation of Fertility by Conservative Surgery for Ectopic Pregnancy Principles and Report of a Case Pendleton Tompkins, M.D. ER the standard tr...

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Preservation of Fertility by Conservative Surgery for Ectopic Pregnancy Principles and Report of a Case

Pendleton Tompkins, M.D.

ER

the standard treatment of tubal pregnancy has been total or partial salpingectomy; in either case the patency of the tube is usually lost. Since salvage of the oviduct is easily accomplished, a plea for conservative surgery in ectopic pregnancy is the subject of this report. GENERATIONS

MANAGEMENT The diagnOSis and immediate preoperative treatment of tubal pregnancy need not be discussed in detail-suffice to say that it is wise to be prepared for transfusion in considerable volume. We ordinarily have two or three 500-cc. flasks of blood at hand but rarely use them. If blood is administered, it is in amounts of 1000 cc. or more. A patient who has lost only 500 cc. of blood probably doesn't need a transfusion any more than the donor who contributed the 500 cc. to the blood bank. Gynecologists who deal especially with infertile women have the best opportunity to detect early ectopic pregnancies. If the patient has a basal temperature record (as she usually does) the fact of pregnancy is obvious without a «pregnancy test." Also, the palpable characteristics of the adnexa are on record and any change is easily recognized. Hence most of the tubal pregnancies occurring in an «infertility practice" will be detected before From the Department of Obstetrics and Gynecology, St. Luke's (Episcopal) Hospital, San Francisco, Calif. Presented at the Twelfth Annual Meeting of the American Society for the Study of Sterility, Chicago, June, 1956. 448

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rupture (Table 1). Even the ruptured ectopics may not be bleeding freely when the tubes are exposed. IIi any case, active hemorrhage is no problem once the pelvic organs are in hand. The tubo-ovarian artery can be clamped TABLE 1.

Summary of Case Report of Mrs. LUN

Born 1922, married 1948 Gravida 1 Mar. 26, 1951 Miscarried Jan. 16, 1953 Feb. 10, 1953

D & E by Dr. Floyd Atwell of Kansas City for early spontaneous abortion. Referred to author for continuation of treatment of relative infertility. Uterosalpingogram (Fig. 3)

Gravida 2 Full term

Feb. 16, 1953 Nov. 9, 1953

Conceived Delivered at term; girl 7 lb. 7 oz.

Gravida 3 Left tubal pregnancy

Oct. 8, 1954 Nov. 29, 1954

"Last" menstrual period. Laparotomy and enucleation of unruptured ectopic pregnancy from distal half of left oviduct at St. Luke's Hospital, San Francisco. Oviduct split with scissors as in Fig. 2. Path. Report S54-4119: "Decidua and chorionic villi compatible with ectopic pregnancy."

Gravida 4 Right tubal pregnancy

Aug. 1, 1955 Sept. 9, 1955

"Last" menstrual period. Laparotomy and enucleation of unruptured ectopic pregnancy from distal half of right tube at Mills Hospital, San "Mateo, Calif. Oviduct split with scissors. Inspection of left tube showed no evidence of operation except that the oviduct was a little shortened, perhaps due to retraction of the linear scar. The fimbriated extremity of the left tube seemed normal. Path. Report M.S55-2471: "Placental fragments from tubal pregnancy."

Gravida 5 Intrauterine pregnancy

Feb. 28, 1956 Mar. 8,1956 May 18,1956

"Last" menstrual period. Salpingogram (Fig. 4) Ten weeks intrauterine pregnancy. No adnexal masses or symptoms of ectopic pregnancy.

with fine hemostats and ligated as shown in Fig. 1, great care being taken not to traumatize the oviduct. With spurting hemorrhage controlled, the surgeon proceeds to deal with the tubal pregnancy in the gentlest possible manner. If implantation is in the distal half of the tube, the oviduct is opened with scissors and, with the tip of the handle of the scalpel, the conceptus is scooped out (Fig. 2).

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If implantation has occurred in the proximal half of the tube an incision can be made with a scalpel and the conceptus enucleated with the scalpel handle (Fig. 1). H,mo.stat.s on tu.bal artery

1 Tu.DO I QL"terles

ll?atecl_

Conceptus eyacuatea ruit./z hanelle 0/ scapel

Ope.rafion cOH1pleted except ZOor closure 0.1' laparotomy Fig. 1. Method of dealing with ectopic pregnancy in the proximal half of the tube. If bleeding is profuse the tubo-ovarian artery can be clamped and ligated without trauma to the oviduct. No attempt is made to repair the tube.

Bleeding from the incision in the tube is not a problem. By lightly pinching the oviduct between thumb and forefinger the ooze can be controlled until the Bovie spark is applied. Ambitious bleeders can be subdued with

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#0000 plain catgut. On one occasion I employed Gelfoam packing to control oozing; the ultimate patency of that tube was not lost. That bleeding during the operation is not troublesome amazes me. Twenty-five years ago

l

I

1 Rt TuiJal Pregnancy

hemostasis with BoY/e or /'ine sutures--

)VO

Opening tuiJe with

attempt is made /"0

repair t".he

scissors

Fig. 2.

Method of dealing with ectopic pregnancy in the distal half of the oviduct. The split tube is not closed.

we used to have blood all over the place and if more than 20 minutes were required to remove a tube, or a tube and ovary, we considered it slow work. Maybe I was more excitable then. Nowadays better anesthesia and

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confidence in the blood bank pennit the gynecologist to work slowly and to conserve the oviduct. Two points deserve the strongest emphasis: 1. Absolutely no attempt is made to close the tube. After the conceptus is removed and the bleeding is controlled, stopl Leave the tube alone. Get outl 2. Free blood in the peritoneal cavity is not evacuated. Only clots which can be lifted out with the hand are removed. Neither sponges, laparotomy packs, or suction is used to remove liquid blood. Leave it there. I do not believe it causes adhesions. To reiterate: Slit the tube, enucleate the conceptus, stop the bleeding, let the tube remain wide open, leave the liquid blood, and close the abdomen. RESULTS This procedure has been followed since June, 1952, in 12 tubal pregnancies in private practice (Table 2). The convalescence in every case was uneventful. Three important questions will be asked: Firstly, how many uterine conceptions followed conservative surgery for tubal pregnancy? The answer: Of 6 "infertility" patients, so far 1 has a uterine pregnancy and 2 had contralateral tubal pregnancies. Secondly, how many ectopic pregnanCies subsequently developed in the tube which had been operated upon? Thus far: None. Thirdly, what proof is there that the patency of the tube is maintained by conservative surgery? Conservative surgery has been employed in 5 "infertile" patients (7 ectopic pregnancies). Three patients have subsequently had salpingograms and none shows any abnormality· in the tube which was operated upon. I have also performed secondary laparotomies on 3 patients (Nos. 1,6, and 8 in Table 2) and inspected the oviduct from which an ectopic had been removed months or years before. These tubes had healed perfectly. I doubt that an uninformed observer would have suspected that surgery had been performed. However, this does not prove that the function of the tube is retained. Proof is provided by one patient in whom an intrauterine pregnancy occurred after bilateral ectopic pregnancies. Her history is abbreviated in Table 1 and her salpingograms are reproduced in Figs. 3 and 4.

-,..------

-.--~-,

-

-,---

TABLE 2.

Summary of Cases of Ectopic Pregnancy and Outcome Following Conservative Surgery

Patient Code name

No.

Date of operation

Hospital

Conceived after ectopic

rLUNa

Nov. '54

St. Luke's

LLUN

Sept. '55

Mills

Yes, contralateral ectopic Yes, uterine

3

CAS

July'55

Peninsula

No (10 mo.)

4

SPI

Feb. '55

St. Luke's

5

JEP

Nov. '53

6

JSWE

7

8

1

Salpingogram after ectopic

"Infer- Ruptility tured patient" ectopic

No x-ray

Yes

No

Both tubes nonnal (Fig. 3 and 4) Both tubes nonnal

Yes

No

Yes

No

No (l5mo.)

Right tube (ectopic) nonnal

Yes

No

St. Luke's

No (30 mo.}

No x-ray

Yes

No

June '52

St. Luke's

No x-ray

Yes

No

LSWE

Jan. '55

St. Luke's

Yes, contralateral ectopic Not trying after second ectopic

No x-ray

Yes

Yes

11

GAL DAV IUS SHI

Jan. '53 Jan. '53 June '53 Oct. '53

St. Luke's Pittsburg St. Luke's St. Luke's

Not trying Not trying Not trying Not trying

No x-ray No x-ray No x-ray No x-ray

No No No No

No No No Yes

12

BIN

Oct. '54

Stanford

Not trying

No x-ray

No

No

2

9

10

~

,...

Notes

For history see Table 1

Consultant's opinion: "Not ectopic" Left tube known to be closed at cornu before ectopic developed in right tube. Consultant's opinion: "Not ectopic"

Ruptured 3 days after D & C and examination under anesthesia for ectopic by author; missed diagnosis.

Consultant: "ectopic"; gynecologist's wife and registered nurse. Husband says he is sterile; Consultant: "Not ectopic." Patient had been in Los Angeles.

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Figs. 3 and 4. The salpingograms show normal tubes and normal distribution of Ethiodol in the pelvis 24 hours after injection. Subsequently intrauterine conception occurred.

COMMENT Surgeons who comfort themselves with the thought that "one tube is enough to raise a family" have felt free to remove all or part of an oviduct containing a pregnancy. But the fact is, unless the patient has had previous salpingograms, there is no assurance that the nonpregnant oviduct is patent, no matter what its appearance. Thus removal of a tube may be tantamount to sterilization. It is much better to save the pregnant tube than to remove it and unknowingly remove all chance of future conception.

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SUMMARY Removal of the conceptus with salvage of the oviduct is advocated in operations for tubal pregnancy. The oviduct is split and the conceptus removed. There is no attempt to repair the tube. A case history with illustrative salpingograms demonstrates that when conservative surgery is practiced bilateral tubal pregnancy can be followed by uterine pregnancy.

ADDENDUM On August 6,1956, Mrs. LUN was 5 months pregnant. Fetal heart sounds were audible. 450 Sutter St. San Francisco, Calif.

Grants-in-Aid The Ortho Pharmaceutical Corporation is providing two $500.00 grantsin-aid for 1957. Applications for these grants should be sent to the Chairman of the Research Correlating Committee of the American Society for the Study of Sterility, Dr. S. Leon Israel, 2116 Spruce Street, Philadelphia 3, Pa. No request will be considered by the Committee unless it is accompanied by three copies of a brief outline of the research project for which the grant of $500.00 will be used.