Where a tubal pregnancy progresses beyond the third or fourth month and invades the broad ligament before giving trouble from internal bleeding, an operation may be necessary at any moment. At this period the operation consists in exposing the parts by a median subumbilical incision, and then opening the gestation-sac, turning out the fœtus, placenta, and clot, and controlling the bleeding by firmly packing the cavity with dabs. The edges of the sac are then stitched to the lower end of the wound; the upper part of the incision is closed, and the sac is drained with a rubber tube of suitable size and allowed to gradually heal.
In cases where the pregnancy continues beyond the fourth month to full time an operation may be required at any moment. Up to the fourth month it may be even possible, in some cases, to remove the embryo, placenta and gestation-sac on the same plan as an ovarian cyst. This is occasionally possible even when the gestation runs to term, but in the majority of cases, when the gestation has passed the fourth month and the fœtus is alive, the surgeon cannot expect to deal with the sac in this summary manner, (unless it be a cornual pregnancy) he has to reckon with the placenta.
Fig. 8. A Gravid Fallopian Tube, containing Twins. (McCann’s case. Museum R. College of Surgeons.) Full size.
In operating for the removal of a gravid tube in the early weeks, the surgeon may be exercised in his mind in regard to the opposite tube, for a careful study of the literature of this subject clearly shows that the patient is liable to conceive in the opposite tube, and in some instances this has happened within a few weeks of the removal of its fellow. The liability of a repeated tubal pregnancy may be fixed at 5 per cent. Moreover, in operating for tubal pregnancy, the opposite tube should be carefully examined, because both tubes may be gravid, though, as a rule, the pregnancies are of different dates. To spare a woman a recurrence of tubal pregnancy it has been urged that the surgeon should remove the opposite tube, but men of ripe experience and judgment are averse to such a proceeding, for it is an established fact that uterine pregnancy is not uncommon after unilateral tubal gestation. My own experience is in harmony with this. In some cases of unilateral tubal abortion the operator has cleared out the tubal mole and clot, and left the tube. This is not good practice: I think a tube which has once been pregnant should be removed. If the opposite tube is obviously diseased, and this happens in a small proportion of patients, it should be removed.
The method of dealing with the sac of an extra-uterine gestation after the fifth month depends in a great measure upon whether the fœtus is alive or dead. The gestation-sac after this date consists usually of the expanded tube closely incorporated with the tissues of the broad ligament, which may be thick in some parts and very thin in others. To the walls of the sac, coils of the intestine, and particularly the rectum, adhere. Experience decides that the safest plan, after exposing the gestation-sac through an abdominal incision, is to cut into it and remove the fœtus and placenta. When the fœtus is dead there will be little trouble from the placenta. The edges of the incision are stitched to the margin of the abdominal wound and drained.
In those rare cases where the amnion erodes the tube and invades the belly (ventral pregnancy), the gestation-sac, with its contents, has been successfully removed by merely transfixing its base with silk ligatures.
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. It cannot be urged with too much force that when it is fairly evident that a woman has an extra-uterine gestation, it should be dealt with by operation without delay: and my experience of the operation leads me to believe that it is a wise plan to remove the placenta at the primary operation. Fortunately very few extra-uterine fœtuses survive to term.
In cornual pregnancy, or, as it is often termed, ‘pregnancy in the rudimentary horn of a so-called unicorn uterus,’ the removal of the uterus is often necessary; there is, however, a variety of this form of pregnancy in which the fully developed cornu may be spared, namely, that in which the rudimentary but gravid cornu is connected with it by a distinct and usually solid pedicle. Many such have been observed and very carefully described.
In nearly all varieties of tubal pregnancy the uterine tissues are sometimes so torn that it is difficult to arrest the hæmorrhage: in this case it is now and then a wise practice to remove the uterus.