ECTOPIC PREGNANCY.* BY

R. S.

Statham, M.D., Ch.M., F.C.O.G.,

Honorary Gynecologist, Lecturer in

Bristol Royal Infirmary; Obstetrics, University of Bristol; AND

H. L.

Shepherd, M.B., Ch.M., M.O.O.G.,

Obstetric Registrar, Bristol Royal Infirmary Obstetric Tutor, University of Bristol.

Ectopic pregnancy is of interest

an

by

no

means

for tlieir

necessary clinical material

rare,

success

depend so very largely early diagnosis that 110 apologies for reporting this series of cases.

and the results upon

members of

to most

Its incidence is

profession.

our

;

seem

The

this paper is based upon which consists of 85 consecutive cases at the Bristol Royal The latter were cases. and 15

Infirmary added

as

in

cases

The

private

they our

included three of the most

interesting

series.

frequency

has been assessed

of occurrence of

variously.

ectopic

Wynne14

pregnancy found it in

gynaecological patients admitted

1 3 per cent, of 22,500 to The Johns Hopkins -

analysis Philadelphia an

of

all

Hospital. Schumann9 made the pregnancies reported in

then obtained figures year, and from all the operators in the area, thus arriving at an estimated incidence of one ectopic in 300 pregnancies. *

A

Society 15

in

one

Paj>er read at a Meeting of the Bristol Medico-Chirurgical held in the University of Bristol on 12th November, 1930.

16

Drs. H. S. Statham

and

H. L. Shepherd

interest to note that up to 1876 this condition was considered a pathological curiosity, which had never been noted at many leading hospitals. But in 1883 Lawson Tait diagnosed and operated upon It is of

a a

some

of tubal pregnancy and reported his result in monograph,11 which started a long series of papers case

upon this most

interesting condition.

pregnancy results from some factor causing delay, or arrest, in the passage of the ovum from the Graafian follicle to the uterine decidua. The following

Ectopic

therefore occur, in theory at any rate : ovarian (1) Primary pregnancy, (2) primary abdominal implantation, (3) tubal implantation, (4) secondary

varieties

can

abdominal

or

implantations, (5) broad (6) pregnancy in an undeveloped

tubo-abdominal

ligament pregnancy,

horn of the uterus. Of these primary ovarian pregnancy is very rare, and the very existence of primary abdominal pregnancy is still denied by most authorities, although a very convincing case has been recently reported, and

Professor Rayner has kindly given me details of a case that he is about to publish, which seems quite

beyond dispute. Causation.

Any factors which

delay in the passage in its journey to the uterus be may originate an ectopic pregnancy. These may conveniently grouped as follows :?

of the fertilized

A. of

can cause

ovum

Persistent foetal convolutions Diverticula leading out of the

Congenital.?(a)

the tubes.

(b)

tubal lumen.3 (c) Accessory ostia, which do not These are said to communicate with the tube. be

fairly

by

us.

common, but have very seldom been

seen

Ectopic Pregnancy B.

17

Conditions

resulting fro?n previous attacks of salpingitis.?This theory was based upon the undoubted fact that very many tubal pregnancies follow upon an attack of pelvic peritonitis, especially if it be gonococcal in origin. It was believed that the ciliary action of the tubal mucosa was the lumen became that and destroyed

locally constricted, up but

so

that

a

spermatozoon could

pass

would be arrested oil its way developing down. These ideas were shown to be erroneous, and Opitz7 demonstrated the most likely causation. He showed that, as a result of previous salpingitis, the long tubal plicse tend to become adherent in places and so form conical pockets with blind ends, into which the ovum

C.

a

ovum

may pass and become arrested.

Webster12

theory regarded as

advanced

might phenomenon, basing pregnancy

be

that

a

an

tubal

atavistic

it upon the decidual reaction in the tube, which he considered a return to the primitive type of uterus. But Bland Sutton states that ectopic pregnancy does not occur in the lower animals though

Blair Bell has described it in rats?and there is

practically On

no

material

proof

of this

theory.

cause of tubal of tubal jDOckets pregnancy is probably the formation of on the and following presence accessory salpingitis,

ostia

the

whole,

the

commonest

and

congenital diverticula will fair proportion of the remaining cases.

account for

a

Varieties. The 100

varieties

cases

were

Primary

Vol. XLVIir.

this

..

..

abdominal pregnancy in

an

series

of

:?

pregnancy

implantation

Pregnancy

in

implantation

follows

ovarian

Secondary

Tubal

as

of

.

?

undeveloped

?

.

.

3 95

?

horn

1

.

.

1 c

No.

179.

Drs. R. S. Statham

18

and

H. L. Shepherd

specimen of primary ovarian pregnancy (No. 1) particularly fine one, in that the sac and embryo It has been reported in detail quite intact.

The was a were

elsewhere.

2

The patient had been treated for sterility of four years' duration by C02 insufflation, and became pregnant two months she developed typical symptoms months later. At of tubal pregnancy, and -an immediate operation was performed, the ovary with the ectopic pregnancy being removed. She has since been delivered of a normal child.

The existence of

ovarian pregnancy was strongly denied for many years by such eminent authorities as Tait and Bland Sutton, but in 1878 " rules" for the Spiegelberg laid down his four

primary

of this condition, viz. (1) the tube on affected side must be intact, (2) the foetal sac the must be in the position of the ovary, (3) the pregnancy

recognition must

be

connected to

ligament, (4)

the uterus

by the ovarian

true ovarian tissue must form its wall.

Since that date numerous cases have been recorded, and these include at least two in which pregnancy has terminated in the formation of lithopsedia (Santti). The three

were

very

of

secondary interesting clinically. cases

abdominal pregnancy

The first patient (No. 2) was between five and six months pregnant, and showed all the symptoms of acute appendicitis. The temperature was 102? and the pulse-rate 112, while there was a definite mass like a hen's egg in the right iliac fossa.

The fact that the pregnancy was very thin-walled was not noticed, and the case was diagnosed as pregnancy complicated At operation the an appendix abscess or pyosalpinx. by " " mass proved to be the fundus of the uterus pushed well back over to the right side by a thin-walled sac containing a foetus. The operation was rendered very difficult by dense adhesions, but the placenta was luckily situated in the pouch of Douglas and was removed intact. The patient made an uneventful recovery, but the child survived only twenty minutes.

Ectopic Pregnancy The second

19

was a primigravida who had missed taken with a sudden attack of pain and vomiting. She came into Bristol, seven miles, in a side-car. She was found to have a biggish uterus with a mass the size of a grape-fruit in the pouch of Douglas, which was diagnosed as a pelvic hsematocele. She refused operation as she had to go on haymaking, and this she did in spite of violent expostulations ! Twelve days later she returned, and at the operation twin foetuses were removed from the pouch of Douglas. The sac wall included the right tube and ovary ; the blood-clot round the sac was already infected, but she made a perfectly normal recovery.

patient (No. 3)

three periods, and

was

The third patient (No. 4) was admitted collapsed, and obviously had had an intraperitoneal haemorrhage. There was a soft mass in the pouch of Douglas. When the abdomen was opened a foetus and placenta were found lying on the back of the right broad ligament, and the placenta was firmly implanted into the back of the uterus and pouch of Douglas. The broad ligament contained old clot, and the case seems to have been

firstly

which

tubal gestation, then a broad ligament pregnancy re-escaped into the peritoneum, and gained a new

a

implantation True

for the second time.

tubal "pregnancy is

much

the

commonest

type of ectopic gestation. The implantation can The average interstitial, isthmic or ampullary. reported frequency is roughly interstitial 3 per be

cent., isthmic 20 per cent, and ampullary 77 per cent., and this series of cases approximates closely

to

these figures. In any variety the fertilized ovum enters the tube, and is arrested during its passage to the uterus by one of the causes already discussed. The trophoblast then settles down, either on a plica, or on the actual wall of the tube between two plicae, and then embeds itself

by

site is the

"

virtue of its

power. The common or between two of the plicae, found lying in the muscularis

penetrative

intercolumn ar,"

is very soon of the tube, and surrounded by a capsule of fibrin from blood-clot and degenerated, muscle tissue so

ovum

20

Drs. R. S. Statham

(corresponding pregnancy), In the

rare cases

H. L. Shepherd

Nitabuch's

to

which

and

separates

of

layer

in

a

normal

it from the tubal lumen.

implantation

on a

plica the

ovum

will, of course, be entirely surrounded by the epithelial lining of the tube, and its area of expansion is then strictly limited. If the implantation takes place in the

narrow

isthmic

portion

of the tube

early

"

"

rupture

will occur, but an ectopic pregnancy situated in the ampullary end may expand its capsule into the tube to a much greater extent before any severe symptoms A slight but definite decidual reaction supervene. occurs in the tube, and decidual cells have been found scattered over the capsule of the ectopic pregnancy in 13- 15 but no true decidua really exists many cases, as a definite structure. The chorionic tissue and placental formation in the tube do not differ from those in intra-uterine gestation, with the exception of the fact that chorionic degeneration is common.5 This was well seen in several of our cases, and the changes in the case of ovarian

pregnancy (No. 1.) were fully studied and illustrated 2 by Fraser in the report upon it. While these changes are taking place in the tube the uterus is also undergoing a characteristic reaction. Definite decidual formation occurs and has been very

fully studied.8 When decidua is expelled in

foetal death supervenes the small scraps accompanied by

bleeding, but

occasionally

complete

it

may

uterine cast

be

(Case No. 59).

passed

in

a

Termination. A tubal pregnancy may terminate in a waj^s: (a) formation of a tubal mole,

abortion,

(c)

intraperitoneal

ligamentary rupture.

rupture,

variety of (b) tubal (d) intra-

Ectopic Pregnancy

21

(a and b) can be grouped together as internal rupture of the capsule," while the second pair (c and d) represent external rupture of the capsule." (a) Tubal mole.?In this condition the blood from the maternal vessels?which have been eroded by the The first two varieties "

"

the lumen of the tube, while the not completely detached. Clotting then occurs round the ovum with resulting fibrosis, and this process being repeated at short intervals results in the formation of a mole. The mole is usually

trophoblast?enters ovum

itself is

expelled into the peritoneal cavity

at

a

later date, mole are

though occasionally fibroid remnants of found at operation which must have been in the tube for years. a

(b) Tubal abortion is naturally

most

common

in

ampullary implantation, and consists of the expulsion of the ovum which has been completely detached by the blood. The ovum and blood are forced into the peritoneal cavity by the contractions of the intact portion of the tube. The colic and accompanying bleeding render it a matter of great difficulty to

distinguish

between

abortion

tubal

and

tubal

rupture.

firmly round the fimbriae of the tube and form a peritubal hematoma." (c) Intraperitoneal rupture.?In this condition the In

some cases

the blood will clot "

capsule of stretched tube, which encloses the ovum, is so eroded and thinned by the trophoblast that it gives way, and very severe bleeding may take place into the peritoneal cavity, which will produce all the classic symptoms of an abdominal catastrophe. In so severe, and the not is cases the many bleeding blood clots about the affected portion of the tube and produces the paratubal hematoma. In other cases

Drs. R. S. Statiiam

22

and

H. L. Shepherd

clotting will take place in the pouch of Douglas, giving rise to a pelvic hematocele." It must be noticed "

that the real

of the

cause

is erosion, and so the term

bleeding

distension of the tube

and

wall, rupture "?long established in our nomenclature?is really a misnomer. As about four-fifths of the tubal surface is covered with peritoneum, it is natural to find this variety much commoner than the next,

not "

viz.

:?

(d) Intraligamentciry rupture.?Here the tube gives way at a point on its wall which is lying over the tissues of the broad

the broad

ligament

hsematoma."

ligament. The blood passes into and distends it, forming a " pelvic

In addition to the above varieties there are three very rare terminations which are occasionally seen. In a few cases of intraperitoneal rupture the ovum be

may

to grow,

reimplanted in the pelvis and continue so produce a secondary abdominal "

and

pregnancy," including the pregnancy." Three cases

so-called are

"

tubo-abdominal (Nos. 2,

here recorded

3 and 4). The ovum in the case of intraligamentary rupture may reimplant itself within the layers of the broad ligament and develop in that situation. Both these may go to full time ; and viable, but deformed infants, have been removed at We have had no case of this at the Royal

varieties

usually term.

Infirmary. Finally,

"

"

may be formed, and be later. This discovered years condition seems to be much rarer than it used to be, probably owing to the a

lithopsedion

great improvement

in

early diagnosis

which has taken

place. In

one

of

our cases

(No. 100) the pregnancy occurred

Ectopic Pregnancy in

a

rudimentary horn,

at the fourth

month,

and gave rise to violent

although

110

23

bleeding

symptoms

at all

had occurred till that time. Diagnosis.

obviously two very different conditions to be diagnosed as ectopic pregnancy, viz. (1) cases of severe intraperitoneal bleeding, and (2) those in which the loss of blood is slight, or has taken place into the tube or broad ligament only. In the first class there is no difficulty in deciding that a very acute abdominal catastrophe has occurred. The patient is blanched, sweating, and cold. The pulse There

are

is thin and rapid. in the flanks, and

Free fluid can be demonstrated usually there is well-marked air

hunger. In these cases the diagnosis is fairly obvious, while there is never any question as to the urgent necessity of operative interference.

It is in the second group of cases that the difficulty of diagnosis arises. Wynne14 states that at Johns Hopkins only 46 per cent, of cases were correctly diagnosed in 1919, while Brady1 in 1923 found it had improved to over 70 per cent, in the same clinic. The correct diagnosis of an ectopic pregnancy is obviously of the greatest importance, and every case operated as having been saved from upon early can be

regarded

grave disaster ; for it is quite impossible to foresee the occurrence of a tubal mole or abortion in place of a tubal rupture. In the first place, we regard the history of a missed period as of little importance. Brady1 found it present a

in

50 per cent, of his cases, and in this series in six had not definitely missed any period at all,

only

one

while in many more this history was doubtful. The complaint of irregular attacks of sharp pain of a colic

24

Drs. R. S. Statham

type is

much

a

more

and

H. L. Shepherd

important symptom, and when this

accompanied by irregular uterine bleedings?usually small in quantity?the diagnosis may be considered to be practically established on the history alone. On pelvic examination it is usually possible to distinguish a mass which is very tender, to one side of the uterus, or in the pouch of Douglas, often associated with enlargement of the uterine artery of that side which can easily be felt pulsating in the fornix affected. The uterus itself will be enlarged and softened and suggests an early pregnancy. In some cases small clots of blood may be felt in the pouch of Douglas. The attacks of colic are due, of course, to the bleeding into the tube and small intraperitoneal haemorrhages, while the vaginal bleeding is the result of the attempts at getting rid of the degenerating decidua, and occurs coincidently with the colic, due to the tubal bleeding which has killed the embryo. A

is

sign which is sometimes of great value, and much vaunted by French gynaecologists, is the rising pain," "

in about 45 per cent, of this series. It consists of passing up from the pelvis and running to the right shoulder, where it persists as a steady

present a

dull ache

ache. In

opinion any woman who has suffered with colic and irregular uterine haemorrhage of attacks should be at once diagnosed as a suspect ectopic pregnancy, and be placed under close supervision. If no alternative and certain diagnosis be found, she our

should be treated

by abdominal section without undue

delay.

operated

series of 29 cases at the upon on the evidence of

found 26

ectopic pregnancies,

In

a

ovarian

cyst, and

1

1

Royal Infirmary, history only, we

pyosalpinx,

normal pregnancy

;

1 twisted an

error

Ectopic Pregnancy rate in

25

of 10 per cent., but only 3-5 per cent, when the question of the need of an operation is considered, and this fully justifies the unnecessary

diagnosis

operations. There is

one

point which cannot be

too

these

unless

insisted upon, and that

vaginal examination possible

in

is the very real

to open the abdomen at

cases,

heavily

danger of it

is

once.

One of the patients in this series (No. 30) was examined in the ward with great care, and almost at once complained of a severe pain. Within three minutes the pulse ran up to 120 and she became pale and collapsed. She was rushed into the theatre, and the abdomen was opened and the bleeding dealt with ; but she lost quite li pints of blood during the few minutes involved in her on to the table and under

getting

the amesthetic. Also, a number of years ago, a case was admitted to a surgical ward at the Royal Infirmary and examined there in bed. The same events occurred, and the patient died before the abdomen could be opened, although there was only a few minutes' delay.

It

desirable

seems

tentative

the

make

to

the

history, diagnosis of an ectopic pregnancy examination confirmation vaginal by delay patient is in hospital, or a nursing home, where she can be operated upon immediately, if on

and to till the

necessary. The chief abortion. "

differential diagnosis

In this series of

immediates," and of these

cases

ten

is from

56

were

were

incomplete

not

obviously

actually diagnosed

products" and curetted, i.e. an error of 18 per cent. The true diagnosis was made in eight of these cases while the patient was on the table, and In the two the abdomen was immediately opened. as

"retained

(Nos. 63 and 97) the condition was diagnosed and both patients died, being the only

remaining not

cases

deaths in the series. It is of interest to note that one of these cases (No. 63) was both an ectopic and an

Drs. R. S. Statham

26

and

H. L. Shepherd

intra-uterine pregnancy. We have found the most to be the fact that colic-like differential helpful points

pain is very unusual the uterus is actually contents, while the

incomplete abortion, unless expelling its bleeding is very much more profuse in

in the process of

tubal pregnancy. Also no swelling can be felt in the broad ligament or in the pouch of of in the case abortion. there In cases where Douglas is a large pelvic hematocele it is possible to mistake

than is usual in

a

swelling for a retroverted gravid uterus, and attempts to reduce it may have diasatrous results (No. 2G). The hematocele may also be mistaken for a

the

twisted ovarian cyst. A case of abortion from

operation

as

observation of a As an aid to introduction of

Douglas

may

for

with

lead colic

was

saved

ectopic gestation by the chance

blue line."

diagnosis in very doubtful cases the an exploring needle into the pouch of

give valuable information. Treatment.

Operation is the only possible form of treatment, the diagnosis lias been made. Even if the to a tubal abortion, it is much safer symptoms point to open the abdomen immediately. Two of these were diagnosed as cases of tubal abortion by competent observers, and yet were found to be early tubal ruptures at operation, and might have bled violently

once

at any minute.

In

remove

possible, tube. three

with

it is our custom to the affected tube and retain the ovary when

cases

slight bleeding

and it is most

important

to

inspect the other unduly rare, and

Twin tubal pregnancy is not of triplets have been recorded.

cases

Also, the

Ectopic Pregnancy other tube may be

The

occurrence

so

diseased

of

an

to

as

intra

-

27

require removal.

uterine

and

tubal

pregnancy at the same time is comparatively frequent. Novak6 records 276 cases, and it occurs twice in our series In

(No. 50 and 63). one

case

occurred in

second tubal pregnancy of the tube removed at a

in this series

the

stump

a

previous operation for ectopic pregnancy (No. 34), a condition of which Hasselblatte3 reports 21 cases. Four of this series had had previous tubal pregnancies

the other side (Nos. 7, 66, 68, 85).* This is quite a usual percentage. Smith10 analysed 144 cases, and on

found that 80 (56 per cent.) became

pregnant again.

Of these 23 were ectopic (28 6 per cent), or 16 per cent, of the whole 144 cases. Other authorities give similar figures, so that Sampson and Smith consider it quite justifiable to remove both tubes at the first operation. ?

This is not

our

custom.

ruptured tubal pregnancy with severe bleeding immediate operation is, of course, indicated, and whenever possible a blood transfusion should be given during the operation. This has a most dramatic effect, and undoubtedly saved the lives of three of In

our

cases

cases.

of

Before

the

abdomen

is

opened

two

Carwardine intestinal clamps are placed ready. The abdomen is opened and the hand is at once plunged down into the and the mass of clot and tube

pelvis, grasped and clamped on both sides, so as bleeding. This should always be done,

bleeding

often

opened, and *

as

it is useless to

Since this paper

was

read

on

as

as

stop the furious

the abdomen is

try and mop

it away

the 12th November another case of

at the Bristol pregnancy has been operated upon list of cases as No. 13 on the in the which is included Infirmary,

repeated

Royal

begins

soon

to

tubal

first occasion.

Drs. R. S. Statham

28

before the to

see

light

clamps

H. L. Shepherd

and

As it is not

applied.

are

if the bowel is adherent to the sac,

bowel

gut which

clamps,

which do

injury

110

possible

we use

these

to any adherent

may be included in their grasp.

The blood

rapidly removed, for which we prefer a suction apparatus, and then the mass between the and clot

clamps

are

is

inspected

and the tube

It is

habit to

removed. blood, for

our

and

pregnancy

the clot and

remove

although it has been stated that the blood with benefit to the patient, we reabsorbed be will cannot but think it is a peritoneal irritant and forms an excellent nidus for sepsis. We have 110 experience

using the blood baled from the peritoneum for transfusion into the patient's vein, which is highly spoken of by many German authors. Rapidity of operation is essential, and immediate steps must be

of

taken to combat shock. heated blanket invaluable. as

We find an electricallyA saline infusion is given

required. We have had

experience of operating upon viable broad ligament pregnancies. Finally, a smear should be examined for gonorrhoea and a Wassermann test done during convalescence. no

Results. Out

of

this

occurred, being remainder

2

per a

100

cent,

of

cases

the

good

recover}^ collected figures of of

operated cases as against 87 treated by expectant methods. The deaths were as follows. uterine abortion, badly infected,

5-7 per

deaths

two

total. and

with the showed a death-rate

comparable which

made

of

series

per cent,

The

this

is

Schauta, cent,

in

in

cases

Case No. 63 had an intrawell as a tubal pregnancy.

as

Ectopic Pregnancy

29

Peritonitis followed the curetting. Laparotomy three days later was followed next day by death from general peritonitis. Case No. 97 was diagnosed as retained products." The temperature was 101? on admission, curetting was followed "

by

acute

and

peritonitis,

on

laparotomy twenty-four

later a necrotic broad ligament pregnancy followed from general peritonitis. On the

diagnosed

cases,

was

found.

therefore, the mortality

hours Death

was

nil.

Summary. In

summarizing

been

faced,

series

owing

our

series of 100

cases

we

have

the great difficulty, classification of those cases which do not show a definite tubal rupture. These cases rank high in our with

viz.

one

The condition found showed a thin tube distended with a blood-clot, but no definite gap in the tube wall. Although many of these would have eroded through in a short time, we have thought it advisable to classify them as " tubal abortion," as the far term "intratubal to

early diagnosis.

preferable

rupture," advocated by Berkeley and Bonney, is in general use. 98

Total cases, 100.?Died, 2 98 per cent.

=

2 per cent;

not

recovered,

=

Site of Ectopic Pregnancy.?Ovarian, 1 ; abdominal, 3; tubal, 88 (intestinal, 4; isthmic, 3; ampullary, 80; stump, 1) ; broad ligament, 7; rudimentary

horn,

1.

Termination.?Abortion,

(intraperitoneal,

38

Clinical aspects

collapsed, Chief

; on

broad

mole, 5 ; rupture, 45 ligament, 7).

45

;

adwissio?i.?Collapsed,

32

;

not

63.

symptoms

haemorrhage,

43

;

in not

collapsed

tumour, 26.

cases:

pain, 55;

30

Drs. R. S. Statham

and

H. L. Shepherd

Previous

ectopic prxgnancies.?4 Age.

20

years

21-30

1

..

,,

..

31-40

?

..

41

?

41

or over

Not stated

..

case

0

cases

1

34

?

2

4

?

3

20

?

4

cases.

Parity. .

.

..

..

.

.

25

cases.

32

,,

13

?

13

?

7

?

8

,,

5 and over

Not stated Years since last

delivery.

2

Weeks since last

?

regular

period. 10

1 year 2 vears

3

?

4 5

?

6

?

7

?

1-2

4

cases.

10

3-4

18

?

..

11

5-6

20

? ?

?

?

5

7-8

25

?

?

8

9-10

5

3

11-12

12

15

13-16

5

13

17-20 20 and

..

more

or

Not stated

cases.

..

.

.

?

1

case.

3

cases.

Lactating

2

,,

Not stated

5

..

over

Ectopic Pregnancy

31

Symptoms.

"5

^ c3

jI

03

Qj

fl

K

20

A.

21

A.

50

A.

Primary Ovarian. ^

23

0

it

++

0

0

0

Tubes insufflated four months previously.

R.

Secondary Abdominal. ^

4

37 i

n

38

??

!

22-}-

0

4-

0

12

0

+

OR.

r

-f-

JO

0

0

+

j

-f

lived Child twenty minutes. Placenta on right broad

ligament. Broad ligament pregnancy ruptured into peritoneal cavity and placental tissue and living foetus in pouch of Douglas.

R,

19 ! A.

Tubal Pregnancy.?Immediate Operations.

10

11 i2

3? it

3.> ax

1

,?7

k r

J?

36 36 33 Or

19 20 21 22

23

24 25 2r 6

1

J

1

On

,7

-

2S ll

oi?

3^ ,

9'-

5 7 12

!

0

;66

9

9

;!0

2s t

30

!

!

?,i

0 0 2 3 3 1

j

1

1

H 8 7 *

A ? ? ? ? 8

:

I * 2(5 3 2 0 2 ? 1 ^ 1.4 : 3 7 I

+ + +

+ l + + I +

I

00'+

j

++ 24? "Xi ? 7 ? ? 12 5

?

I

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I

+ +

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9

10

+ I + + I 0

*

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|

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I

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+ + 0 0

6 16

+

0

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+ 0 0

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0 | + 0 1 + 0 | 0 0 ++, 0 I + I 0 + 0 + 0 1 + 0 +

j

Intravenous saline

Rupture Rupture Rupture

two at Hull. Interstitial also interuterine pregnancy. Isthmic years

! Rupture Rupture Rupture Rupture Right

Rupture1 i

Rupture

Rupture!

Rupture Rupture Rupture

ectopic

Previous

J

..

tube

ligated

Blood transfusion Intravenous saline

also ..

..

j Intravenous saline, vide No. 68.

R. Rupture ; R. Rupture j *Lactating R. j Rupture | Tubo-ovarian pregnancy ? Rupture: R. Rupture L. Rupture j L. Rupture : Intravenous and saline R. i Rupture , R. ! Rupture I Ruptured when retroversion was reduced. i||

j

j

j

A. A. A.

ago

j

j

30 16 21

29 A. 20 A. 26 A. 18 I A. 17 A. 29 A. 14 A. 24 A. 17 A. 29 A. 21 13 15 23 14 21 18 28 14

A. A. A. A. a. A A. A. A.

32

Drs. R. S. Statham

H. L. Shepherd

and

Symptoms. o O r*

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Abortion

(1) Curetted and removal of septic intra-uterine abortion.

(2) Peritonitis 3 days later?laparotomy and removal of septic tubal 12

0

+

+

+ +

+ +

+ 0

5.0

+

0

R

Abortion

abortion. Drainage. Curetted, but diagnosed on

table.

tosalpinx 6 9

o 0

R. R.

Abortion Abortion

Vide ^No.

L

Abortion

Curetted 3 weeks previ-

40.

Previous

ectopic.

ously

for

6

+

0

0

L.

Abortion

4

+

0

0

R.

Abortion

Left

3 16 4

+

+ 0 +

7 4

5 12

+ 0

0 4 3 0 6 1 0

4 + ' 0 12 I + + 4 0 + 3 + + 6 ; + : +

+

4+0 ' 6 + +

0 0

5 2

+

0 1 1 2

H 10

H

1 2 1 3

1 4 3

4 3 7 1 1

l'j ? 6 3 8

0

V?L. XLVIII.

+

+

+ +

+

:

+ +

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:

0 0 0

0 0 0 0

f + 0 0

6 0 + ? ! + ! + 12 0 + ? 0 + : 3 + +

0 0 + + 0

0 ! + + +

0

6 8

+

!

No. 179.

ovarian.

Double

salpingectomy.

Abortion Abortion on Abortion Curetted, diagnosed table. Abortion Left ovarian dermoid Abortion Curetted and diagnosed on table. Abortion Abortion Abortion Abortion Abortion Abortion extruding Abortion Polypus through cervix, hysterectomy. ovarian Rupture Small left ..

0 0

0

7+0 6

0 0 0

ectopic.

+

o o

L. L. R. R. L. R. L.

L. R.

Rupture Rupture Rupture

L. L.

Mole Mole

24 14 11 18 35 31 30 21 17 21 21 16 21 18

vide

Curetted and diagnosed

21 18 22 18 23

Appendicectomy Previous

ectopic,

No. 62.

Rupture Mole Mole

23

22 23 17 18

Rupture Rupture R.

17 14

chronic Sub-

uterine sepsis. total hysterectomy. Previous Vide No. 17.

1

18

Left hasmaalso removed.

on

Right

table. tube

ligated

also

20 17

34

Ectopic Pregnancy

j"? j

|-a

I

Symptoms.

a -p

i

'pce

|

O G

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S

1

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*

0

H

Broad Ligament Pregnancies. 35

93

12

+

+

+

I ?

94

?

95

!++

R-

Broacl

Ligament

venous

I

?

1

G

j

0

+

3

+

+

;

+ j

0

!

0

+

R.

30

2

V

-f1

43

97

3

12

+

4-

0

0

| Ligament

L.

+

+

0

L.

Ligament Broad

Ligament

36

98 99

j

27 :

?' 0

j

27

1

'

Curetted as intra-uterine abortion. 2 days later acute peritonitis. Gas, macerated and pus, foetus in broad liga-

8 ,

+

11 I +

+

j

+

++ 0

16

+

0 0

R. R.

Broad

| Ligament

Appendix

removed

16

Broad

0

0

in

+ +

Rudimentary Horn. L.

Rupture Ruptured left rudimentary

REFERENCES. 2 3 4 5 5 6 7 8 9 10 11 12 13 14 15

i

P-

Brady,

Johns

Hopkins Hosp. Bull, 1923,

xxxiv. 152.

Fraser & Statham, Jour. Obst. and Gyn. Brit. Evip., 1927, xxxiv. 788, Hasselblatte, Acta Obst. et Gyn. Scandin., 1927, vi. 211. McNally, Amer. Jour. Obstet., 1926, xii. 303. Meyer, Surg. Gyn. and Obstet., 1919, xxviii. 293. Contribution to Embryology, 1920, ix. 327. Novak, Surg. Gyn. and Obstet., 1926, xliii. 26. Opitz, Ztschr. f. Geb. u Gyn. Stuttg., 1902-3, xlviii. 538. Sampson, Trans. Amer. Gyn. Soc., 1913, xxxviii. 121. Schumann, Extra-uterine Pregnancy, Monograph, 1921. Smith, Surg. Gyn. and Obstet., 1914, xviii. 684. Tait, Lecture on Ectopic Pregnancy, 1888. Webster, Ectopic Pregnancy, 1895. Williams, Whitridge, Obstetrics, 1930, p. 789. Wynne, Johns Hopkins Hosp. Bull., 1919, xxx. p. 15. Young, Edin. Med. Jour., 1909, iii. 118.

Meyer,

24

Ligament

horn with abdomen full of blood.

1

s

A'

ment.

?

Pregnancy 100

I A-

? "

23

Broad

Ligament

28

21 1 A-

L. | Broad

,

1

saline.

Broad

;

96

Secondary rupture into Intraperitoneum.

11

A'

Ectopic Pregnancy.

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