MARCH, 1975

Chronic Ectopic Pregnancy JOHN F J. CLARK, M.D., Professor and Chairman, and WILLIAM BRYANT, M.D., Resident, Department of Obstetrics and Gynecology, Howard University College of Medicine and Freedmen's Hospital, Washington, D.C.

MI~,faternal mortality has steadily decreased

jYlin the United States. From 1915 to 1919, the rate of maternal death was 728/100,000 live births. The rate for nonwhites during the same period was 1,253/100,000 live births. In 1963 the rate had improved to 24/100,000 live births for whites and 96/100,000 live births for nonwhites. 1-6 For many years the five leading causes of maternal mortality were: toxemia, hemorrhage, abortion, sepsis of pregnancy and ectopic pregnancy. In 1963, there were 93 deaths due to ectopic pregnancy nationwide. Of this number, 35 were white and 58 nonwhite. More revealing was that the rate of death from ectopic pregnancy in 1963 for all ages was 9:1 nonwhite to white. In the District of Columbia there have been 26 deaths due to ectopic pregnancy from 1955 to 1971. Only one fatality was white. In 1971 there were four maternal deaths in the District, three were ectopic pregnancies.4 In general, the improvement in maternal mortality has gone hand in hand with the advent of antibiotics, perfection of blood storage and transfusion, improvement in diagnostic and treatment facilities and public education. However, the improvement in mortality for nonwhites has not kept pace with the improvement for whites. Specifically, ectopic pregnancy still takes a significant number of lives. Even more glaring is the death rate of nonwhites. The physician, black and white, must share a significant responsibility for this discrepancy. An old medical cliche states, "There are two diagnoses a physician will never make, the one he doesn't know about and the one he doesn't think about." This old saying illustrates the

problem of diagnosing ectopic pregnancy. All of us know about ectopic pregnancy but many of us don't think about it. This is especially true with regard to black women, who are labeled as having pelvic inflamatory disease or anything else, far too often. With the rise of ectopic pregnancy to fifth in maternal mortality, it is hoped that the cliche "any young black woman with stomach pain has PI.D.", will soon die. A few subtleties in the diagnosis of ectopic pregnancy will be presented from the Freedmen's experience 1968 to 1972. An ectopic pregnancy is implantation of the fertilized ovum outside the uterine cavity. Clinically, ectopic pregnancy may present in two forms acute and chronic. In the chronic form, symptoms and signs of shock or near shock are difficult to demonstrate, and they are more subtle in nature. The incidence of ectopic pregnancy is variable, ranging from 1 in 300 to 1 in 28. An incidence of 1 in 120 has been reported in black women in Baltimore, and 1 in 64 at Harlem Hospital. At Freedmen's Hospital, there have been 9,041 4ive births from 1968 to 1972, during which time 109 ectopic pregnancies were diagnosed, for an incidence of 1 in 90. Of the 109 ectopic pregnancies, 70 were classified as acute and 39 as chronic.7 ACUTE ECTOPIC PREGNANCIES

Age and Parity The age range among the acute group was 18 to 38 years with a clustering occurring in the 25 to 29 age group. Among the chronic group, the range was 19 to 44. Forty-five of the acute group had a parity between one and three. Eleven of the acute group, and nine of the chronic group gave a nulliparous history.

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Ectopic Pregnancy

Symptomatology. The most common symptoms among the acute group were classically amenorrhea, an abnormal bleeding episode, and abdominal pain (Table 1). Amenorrhea was present in 100% of parents. The last normal menses was two months or less on admission in 78%. One or more episodes of abnormal uterine bleeding were described by 75%. Thirty-five percent of these patients were bleeding or spotting on admission, or had bleeding or spotting the week of admission. TABLE 1. SYMPTOMATOLOGY-ACUTE ECTOPICS

Symptoms Amenorrhea Last Normal Menstrual Period two months or less Abnormal Bleeding Abdominal Pain Unilateral Cramping Sharp or Tearing Early Pregnancy Symptoms

Percentage 100

78 75 68 46 22 54

Abdominal pain was described in a total of 68%. Forty-six percent of these patients complained of a unilateral crampy pain. A sharp or tearing pain was described by 22%. Symptoms of early pregnancy, as a group, was the fourth most common symptom. Nausea, vomiting, dizziness, weakness, breast tenderness and malaise were decribed by 54%. Symptoms appearing less frequently were syncope 28%, shoulder girdle pain 22%, sense of pelvic fullness or diarrhea 18%, and urinary frequency and urgency 15%. Chills and fever were described by 11%, vaginal passage of tissue by 5%, and dyspareunia by 4%. Physical Examination. Examination of the patient with ectopic pregnancy may not be completely rewarding. Frequently the patient presents with minimal findings (Table 2). A temperature of 99.8+ or less was seen in 75%. Only seven patients had temperatures of 100+ or above. Pulse rates of 100/min. or less were seen in 75%. Sixty-seven percent had abdominal tenderness with which 44% also had rebound tenderness. Blood pressures of 120®0 or slightly less were seen in 63%. Only nine patients were in shock on admission. Pelvic examination was not completely rewarding. This was probably due to the difficulity in examining patients with abdominal tenderness. Where an adequate examination


could be done, an adnexal mass or fullness was palpated in 40%. Movement of the cervix elicited pain in 28%. Cul-de-sac fullness was apparent in 21%. Speculum examination revealed a cyanotic cervix in 18% and a soft cervix was described in 8%. The uterus could be described in only 23 patients. Seventeen were reported to have an enlarged uterus. TABLE 2. PHYSICAL EXAMINATION

Signs Temperature of 99.8° or less Pulse of 100/min. or less Abdominal Tenderness Rebound Tenderness Blood Pressure of 120/80 Adnexal Mass or Fullness Pain on Moving Cervix Cul-de-sac Fullness Cyanotic Cervix Soft Cervix Uterus Enlarged

Percentage 75 75 67 44

63 40 28 21 18 8 17

Diagnositc Procedures. Culdocentesis was the most rewarding diagnostic procedure. Of the 47 patients on whom it was performed, 41 positives were obtained. Hemoglobin and hematocrit determinations may be misleading unless done on a serial basis. Fifty-seven percent of the acute group had initial hemoglobins of 10.0 gm. or better, and hematocrits of 30% or better. Pregnancy tests were positive in nine of the 15 patients on whom it was performed. CHRONIC ECTOPIC PREGNANCY

Symptoms of chronic ectopic pregnancy may be more subtle. The three most common complaints were amenorrhea, abdominal pain and abnormal bleeding7 Amenorrhea was present in 100% of the patients. The last normal menstrual period was two months or less, prior to admission, in 62%. However, 38% of the patients had last menstrual periods longer than two months prior to admission. Abnormal uterine bleeding or spotting was seen in 77% of patients. Seventy percent had this complaint longer than one week prior to admission. Seven percent had the same complaint for less than one week prior to admission (Table 3). Abdominal pain was present in 80%. The pain was described as crampy by 67% and sharp by 12%. Pain occurring shortly after the last normal menstrual period was seen in 60%.



Twenty percent of the patients complained of pain the week of admission. Symptoms of early pregnancy were seen in 58%. Nausea and vomiting were the most common complaints, seen in 37%. Less frequent complaints were rectal fullness or diarrhea in 20%, shoulder girdle pain in 12% syncope in 10%, dyspareunia in 7%, and passage of tissue in 1%. TABLE 3. SYMPTOMATOLOGYCHRONIC ECTOPICS Symptoms Percentage 100 Amenorrhea Last Normal Menstrual Period two 62 months or less Last Normal Menstrual Period two months or more 38 77 Abnormal Bleeding Bleeding or Spotting more than one week prior to admission 70 Bleeding or Spotting less than 7 one week prior to admission 80 Abdominal Pain Early Pregnancy Symptoms 58

Physical Examination. The findings on physical examination were little different from that of the acute group. Again, vital signs were generally stable. A pulse rate of 100/min. or less was seen in 80%. Blood pressures of 120/80 or slightly less, were seen in 67%. As with the previous group, temperatures of 99.90 or less were present in 60%. Abdominal tenderness was elicited in 60% of patients. Twenty-five percent had rebound tenderness

(Table 4). Pelvic Examination. Pelvic examination was not more revealing in this group. An adnexal mass or fullness was appreciated in 37%. The cervix was judged cyanotic in 25%, and soft in 25%. The uterus was enlarged in 22% of the patients, also pain on movement of the cervix was elicited in22%. Laboratory and Diagnostic Procedures. Seventy-two percent of this group had hemoglobins of 10 grams or better, and hematocrits of 30% or better. Further, these values tended to remain stable with serial determinations. Of the 20 patients who had pregnancy tests, 12 were positive. Culdocentesis, done on 14 patients, yielded only five positives. Dilatation and curettage was done on 14 patients, six of whom had endometrium described as decidual

MARCH, 1975

reaction. Two were described as Aria-Stella reaction. The remainder were described as either secretory or proliferactive endometrium. A consistent finding was the number of times they were seen by physicians and the resultant diagnoses and therapy they received before the correct diagnosis was made. Thirtyfive of the 39 patients were seen by private physicians or physicians in emergency rooms before the diagnosis was made. Twenty-two patients were seen one or two times after the primary visit. Six patients were seen three or four times after they primary visit. Among the TABLE 4. PHYSICAL EXAMINATION


Signs Blood Pressures of 120/80 or less Pulse of 100/min. or less Temperature 99.80 or less Abdominal Tenderness Rebound Tenderness Adnexal Mass or Fullness Cyanotic Cervix Soft Cervix Uterus Enlarged Pain


80 60 60 25 37 25 25 22 22

diagnoses were pelvic inflammatory disease, 13 abnormal uterine bleeding,7 incomplete abortion,4 threatened abortion,3 appendicitis,2 intrauterine pregnancy, 2 dermoid cyst2 and ovarian cyst' and cholecystitis.' DISCUSSION

Chronic ectopic pregnancy is not emphasized in the newer textbooks. It is thought to result from slow leakage of blood into the abdominal cavity, or the tubal lumen. This results in adhesions, walling off, and hematocele formation. As a result of the slow leakage, the complaints of the patients are spread over a longer period of time. In our series, a palpable mass was the most significant finding in the chronic group. A mass was palpable in 37% of the chronic patients, and in only 22% of the acute patients. Abdominal tenderness was more prominent in the acute group, being present in 83%, as opposed to 60% in the chronic group. There was little difference in the other signs. Crampy pain and spotting or bleeding, as one would expect, had persisted for a longer

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period of time in the chronic group. There was also a slight difference in the complaint of pain. Crampy pain for a persistent period was the complaint with 52% of the chronic group and 46% of the acute group. In general, the diagnosis of ectopic pregnancy is made mostly from history. Eliciting a history of amenorrhea is important, but more significant is a history of abnormal uterine bleeding, including spotting. The relationship of abdominal pain to the last normal menses is also important. Classically the pain of pelvic inflammatory disease is more apparent during TABLE 5. ERRONEOUS DIAGNOSES Pelvic Inflammatory Disease Dysfunctional Uterine Bleeding Incomplete Abortion Threatened Abortion Appendicitis Intrauterine Pregnancy Dermoid Cyst Ovarian Cyst Cholecystitis

Nuimber 13 7 4 3 2 2 2 I 1

the menstrual period. The pain of ectopic pregnancy occurs some time after the last normal menstrual period. Symptoms of early pregnancy should arouse suspicion. Nausea, vomiting, and weight gain are classic, but the physician should keep in mind that dizziness, malaise, urinary urgency and frequency, breast tenderness, and weight loss may be present when the classical symptoms are absent. A past history of tubal plastic surgery or pelvic inflammatory disease should arouse suspicion. However a history of pelvic inflammatory disease should be interpreted with caution. A previous study at Freedmen's Hospital of 436 surgical ectopic pregnancy specimens showed 58.2% with no pathologic lesion, that is, no evidence of pelvic inflammatory disease in the tubal specimen. It should also be emphasized that a patient with a previous tubal ligation is not immune to ectopic pregnancy.


With regard to this, it remains to be seen what effects laparascopy tubal cautery will have on the incidence of tubal pregnancy in these patients. On physical examination a subnormal or normal temperature should be suspect, especially in the patient with a working diagnosis of pelvic inflammatory disease. The results of an inadequate pelvic examination should not be relied upon. It is better to admit for observation in this situation. One aspect of the pelvic examination should be emphasized and that is a positive Bolt's sign, or pain on motion of the cervix, is not diagnostic of pelvic inflammatory disease. Pain on movement of the cervix can be elicited during a normal menses, with cervicitis, in pelvic inflammatory disease, with severe retroverted uterus, and with ectopic pregnancy. Culdocentesis, from a practical standpoint, can not be done on every patient. If culdocentesis is warranted, the patient should be hospitalized even if the "tap" is negative. Finally, laparascopy has been a great help in diagnosing ectopic pregnancy. With the liberal use of this instrument, the physician no longer waits in confusion for the patient to make the diagnosis for him. LITERATURE CITED

1. DANFORTH, N. Textbook of Obstetrics and Gynecology. Harper and Row Company, 2nd Ed., New York, 1971. 2. KIMBROUGH, A. Gynecology. J.B. Lippincott Co., Phila., 1965. 3. BREEN, J.L. A 21-Year Survey of 654 Ectopic Pregnancies. Amer. Jour Obset. Gynecol., 1970. 4. Department of Human Respurces, District of Columbia, 1955-1971. 5. SHAPIRO, S. Infant, Perinatal, Maternal and Childhood Mortality in the United States, Harvard Univ. Press, Cambridge, Mass., 1968. 6. Public Health Service-National Center for Health Statistics: Infant, Fetal and Maternal Mortality in the United States. U.S. Dept. of Health, Education and Welfare, 1963. 7. NILES, J.H. and F J. CLARK. Pathogenesis of Tubal Pregnancy, Amer. Jour. Obstet. Gynecol., 105: 1969.

(President's column, from page 171)

cal Associatoin should continue to remain content, until our third major recommendation; namely, the enactment of a "Little Marshall Plan" for Macon County, Alabama, is effectuated. Such a demonstration will be

successful with the proper will and resources and can serve as a basis for replication in the other "Macon Counties" in America. VERNAL G. CAVE, M.D., FA.C.P

Chronic ectopic pregnancy.

118 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION MARCH, 1975 Chronic Ectopic Pregnancy JOHN F J. CLARK, M.D., Professor and Chairman, and WILLIAM BR...
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