At the Time of Rupture.—Many cases of tubal pregnancy are first seen at the time of rupture. In such cases celiotomy should be performed without delay. The condition is most urgent in intraperitoneal rupture, but it is the safest rule to operate immediately, whether the rupture be intraperitoneal or extraperitoneal. It is unwise to wait for reaction. The physical depression in such cases is due more to hemorrhage than to shock, and it is in accord with general surgical principles to arrest hemorrhage at once.
Rupture usually takes place before the twelfth week, and the whole product of conception, with the tube, may readily be removed. Hemorrhage usually ceases as soon as the proximal and distal ends of the ovarian artery are ligated. The ligatures may be placed about the ovarian artery, at the pelvic wall, and at the uterine cornu, as the first steps of the operation, before any attempt is made to remove the mass. It may be necessary to close the rent in the broad ligament by a series of sutures.
After Rupture.—If the woman survive, and is first seen after primary rupture, one of two conditions will be present—a destroyed or a developing extra-uterine pregnancy. If the fetus has died and gestation has ceased, the woman is exposed to the various dangers that attend the presence of such a foreign body in the abdomen. If the fetus has died during the earlier months, it may have been absorbed and spontaneous cure may take place. Even a dead full-term fetus has been carried in the abdomen for years without producing a fatal result to the mother. It seems safest, however, in all such cases to operate as soon as the condition is recognized. The rules of abdominal and pelvic surgery apply to such cases. The placenta of a dead fetus may be removed without fear of uncontrollable hemorrhage.
If the woman is seen after primary rupture, with a developing gestation, the case presents much more serious dangers. These dangers lie in the placenta. If the pregnancy has not advanced beyond the fourth month, it is usually possible to remove the whole of the gestation-sac, the embryo, and the placenta without uncontrollable hemorrhage. The ovarian, and if necessary the uterine, arteries may be ligated, and the placenta may be removed in one mass. The cavity of the broad ligament may be obliterated by buried sutures.
If the gestation has advanced beyond the fourth month, it is often impossible to remove the placenta without fatal hemorrhage. Many women have bled to death from the attempt. The operator sometimes incises the placenta as he enters the gestation-sac, and is obliged to proceed with its removal. In other cases he starts to remove it, and finds, too late, that the hemorrhage is beyond his control. In the advanced months of pregnancy the sac and the placenta may become adherent to any of the abdominal or pelvic viscera and to the large vessels. Hemorrhage cannot be controlled, as in the earlier months, by ligation of the ovarian and uterine arteries. The result in these cases is determined by the ability of the operator. A full-term living child, the whole sac, and the placenta have been successfully removed. If the attachments are such that the surgeon considers it unsafe to attempt the removal of the sac and the placenta, the sac should be incised and the fetus should be removed, the cord being divided between two ligatures; the sac should be sutured to the abdominal incision; the cord should be drawn through the opening, and the sac packed with gauze. At the end of four or five days the gauze pack may be removed, under anesthesia if necessary, and the placenta may be taken away. There is very much less risk of hemorrhage after the lapse of a few days. Some operators prefer to allow the placenta to come away spontaneously. This is sometimes necessary.
It will be seen, from this consideration, that the treatment of all varieties of ectopic gestation is operative, and that the sooner the operation is performed the better for the patient. Consideration for the life of the child should have no influence in determining the time of operation.
Ovarian Pregnancy.—The possibility of the implantation and development of the fertilized ovum in the Graafian follicle has been denied by many authorities. It seems probable, however, that such a form of pregnancy does very rarely occur. The cause of ovarian pregnancy is thought to be due to some disturbance of the normal process of ovulation, whereby the ovum fails to leave the ruptured follicle and is there fertilized and developed.