Paper - Clinical and embryologic report of an extremely early tubal pregnancy
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Dorland WAN. and Bartelmez GW. Clinical and embryologic report of an extremely early tubal pregnancy; together with a study of decidual reaction, intra-uterine and ectopic. (1922) Amer. J. Obst. Gynecol, 4: 215-227 and 4:372-386.
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- 1 Clinical and, Embryologic Report of an Extremely Early Tubal Pregnancy - Together with a Study of Decidual Reaction, Intrauterine and Ectopic
- 1.1 I. A Very Young Tubal Embryo
- 1.2 Embryologic Findings on Dorlann’s Specimen
- 1.3 Somites=
- 1.4 A Comparative Clinical Study of a Group of Early Ectopic Pregnancies
- 1.5 Determination of Embryonic Age
- 1.6 Summary
Clinical and, Embryologic Report of an Extremely Early Tubal Pregnancy - Together with a Study of Decidual Reaction, Intrauterine and Ectopic
By W. A. Newman Dorland, A.M., M.D., F.A.C.S., Chicago, Ill.
Embryologic Report By George W. Bartelmez, Ph.D., Chicago
Read before the Chicago Gynecological Society, April 21, 1922.
Note: The Editor accepts no responsibility for the views and statements of authors as published in their “Original Communications.”
I. A Very Young Tubal Embryo
In November 17, 1916, I presented before the Chicago Gynecological Society the Wet specimen of a tubal pregnancy removed three days before, together with a Water-color drawing showing the exact size and appearance of the tube and gestation sac at the time of removal. Service in the United States army during the War and other unavoidable delays have prevented an earlier complete report of this case. The history of the patient is as follows:
Mrs. K. twenty-six years of age, had given birth to a male child six years before the present conception, and had not been pregnant since. There was no history of pelvic disease at any time. The menstrual record Was normal, the last period covering from September 29 to October 5, 1916. There was no re‘turn of the menses on November 1, and on Friday, November 10, the patient suffered an acute attack of pain in the right lower quadrant of the abdomen which was of sufficient severity to cause her to faint. There was no vaginal bleeding at this time nor any prior to the "date of operation. Dr. Norman Kerr saw her at the time of the_ attack and pronounced the condition either tubal pregnancy or appendicitis. The patient experienced another attack of pain of less intensity later in the same day, and a third attack, also of but slight severity, on Sunday morning, November 12. Dr. Kerr new positively diagnosed a tubal gestation and advised immediate removal to the Polyclinic Hospital. There was at no time any elevation of temperature.
That evening (November 12) I was asked to see her. The examination at this time elicited tenderness in the region of the right broad ligament, but no mass could be detected. The uterus was slightly, but distinctly, enlarged. A presumptive diagnosis of early ectopic pregnancy was made and immediate removal to the hospital advised.
The patient was admitted to the “Test Side Hospital that evening, and at eight o’clock, Tuesday morning, November 14, I made an exploratory incision. The appearances were those of an early normal intrauterine gestati.on.. The uterus was enlarged as if the seat of a conception. Both tubes appeared absolutely normal; there were no adhesions, no discoloration, and no nodules to be detected by the eye on either side, nor was there any trace of free blood or clots in the pelvic sac. The general opinion of those present was that we had to deal with a very early pregnancy in mere. There was a fresh, vvell—marked corpus luteum on the uppe.r posterior surface of the left ovary. The vermiforrn appendix was healthy.
I felt, however, that there must have been some cause for the attacks of colicky pain, and on gentle palpation of the right fallopian tube a very minute kernel could be felt near its middle point. The tube was removed and the ab_domen closed, the patient making a speedy recovery. ‘An incision on the upper aspect of the tube opened into what seemed t.o be a normal lumen, but when the incision was extended slightly, a pearl-like globule. as is Well shown in Fig. 1, came into view, conﬁrming the diagnosis -of a. very early tubal gestation. The intact specimen, after its presentation before this Society, was given to the pathologist, Dr. George W. Bartelmez, of the Anatomical Department of the University of Chicago, T-‘l-‘ll0 made the f0llOW1ll.g report.
It is usually difficult to estimate the age of pregnancies of the ﬁrst month and none of the early tubal pregnancies that have been reported have any reliable data for determining the age. Our only recourse then is to estimate the age "from the stage of development reached by the embryo.
The only young tubal ova in which embryos were found are those of Penkert (19-11) and Johnstone (1914). In both the embryos were so badly injured in opening the tube that it is Well nigh-impossible to place them in the series of young human embryos, at least from the descriptions that have been published.
Penkert’s ovun came from an unruptured tube removed because of its size and suspiciously congested appearance in the course of an ovariotorny. The cavity of the ovum, as calculated from a fairly complete series of sections, measured 12.1 x 7.54 X 4.75 mm. The villi at one pole of the ovum were extraordinarily long, to judge from his ﬁgure, or else the extraembryonnic celom was larger than the ﬁgure indicates. In any case", it is probable that before dehydration and imbedding the dimensions of this ovum, including the‘ villi, were greater than any of those in Table I, vvhich were all measured in formol before dehydration. In an ovum of this size one would expect to ﬁnd an embryo of 14 to 20 somites and about 3.5 mm. long. The fragment which Penkert identi ried in his sections probably came from the caudal end of the embryo, but he could not be certain of this. It is impossible to come to any conclusion from his ﬁgures and description since what he labels amnion has bloodvessels and bloodislands in its wall. This might, of course, be the region of the amniotic duct in the belly-stalk, but he states that he failed to recognize this latter structure. He concluded that the embryo Was in about the same stage as the StrahlBeneke specimen. This is not at all probable, not only because the chorion is altogether too large but because the structure he has called amnion is also too large. There are two: possibilities which this author did not discuss. One is that most of the embryo was lost and that he had in his sections only the primitive streak-end. The absence of lateral body-folds in the sections illustrated milit.ates against this, but the great distortion might have eliminated them. The second possibility is that the embryo developed more slowly than the. chorion and, in spite of the presence of mitotic ﬁgures, it may have been very abnormal in form. It is not at all uncommon to ﬁnd an embryonic rudiment resembling a primitive streak in tubal ova as well or in abortions of the ﬁrst month. Considering the diseased condition of the ovaries of this individual it may Well be that the ovum produced was not capable of normal development. In any case, the emb1'yonic..fragment gives no reliable evidence as to the age of the pregnancy.
Penkert’s estimate of the age rests entirely upon his naive acceptance of the patient ’s statement that the precautions against fertilization were omitted on only one occasion, namely on the day that a menstrual period was due. This expected ‘period failed to app-ear. The obvious explanation of this is that the ovum was already implanted in the tube at the time of the supposed fertilization and that the ﬂow was inhibited in the usual manner. This is far m.ore probable than to assume, as Penkert does, that development proceeds much more rapidly in tubal pregnancies and that this relatively large ovum was younger than the Bryce-Teacher specimen. There is no reason to doubt that the ovum before it is implanted must pass through a deﬁnite series of transformations which take about eight days, whether the ovum be passed on to the uterus or whether it is held back in the tube. If We add this time to the period that elapsed between the date of the lapsed period and the operation we get a minimum age of 21 days which agrees roughly with the size of the ovum as compared with uterine ova of this age. As we shall see in some cases tubal ova are decidedly smaller than uterine ova containing embryos of the same stage. Certain features of the placental anlage also indicate" an age of three weeks or more. They are the great development of ‘Haftzotten.’ large masses of cytotrophoblast, and the appearance of mesodermal cores in all villi. The author ’s statement that ‘all’ villi are already vascularized indicates a four weeks’ placenta.
Johnstonc’s ovum was implanted on the ﬁmbria tubes of a patient who had not- missed a period. He gives no dimensions for his ovum, and the embryo was injured mechanically and also somevvhat macerated. He came to the conclusion that it belongs in the series between the Glaeveke and the PfannenstielKroemer embryo. (These are numbers II and III respectively of the Kiebel and Elze .Normcnta_fcZ, 190-7.) The ‘former is an early neural plate stage; the latter has the neural groove open throughout its entire length. All of the sections that are ﬁgured in J ohnstone’s paper are through the caudal end of the embryo‘ and all show the nervous system as a closed tube. Johnstone concluded that the sections passed transversely through the fragment of the embryo but that they were oblique in the rostro-caudal direction. Now, since the closed neural tube appears in a section which ventrally passes through the allantoic diverticulum we may conclude that the neural tube wa.s closed ‘practically as far as the primitive streak. This would indicate an embryo of 14 or more somites. John~ stone gives two possible lengths for his embryo based upon the number of sections in which embryonic fragments are present. One is 1.6 mm. the other 2.142 mm. He was doubtful as to whether it was quite normal.
Dorlandis embryo is the youngest in which the data permit of a reliable determina..tion of the age. The welhpreserved embryo corresponds to certain others which ra.nge between 20 and 21 days after the fruitful coitus. Numerous smaller tubal ova have been described, as, for example, by Mall (1915, tables 3 and 13; see especially No. 75-1.») but they are all pathological and there are no data to indicate how long they were implanted or to what extent their growth may have been retarded in obviously diseased tubes.
The youngest normal. embryo reported by Mall in this study of 146 tubal pregnancies was No. 808 which was -4: millimeters long. He gives its menstrual age as six weeks. ' '
The clinical data concerning our specimen have been given above. If we assume that the development of the entire product of conception was retarded or halted at the time of the first serious attack on November 10, then fertilization occurred in the third week of the menstrual cycle which began September 29. This is ‘taking for granted that its age is three weeks. Accordingly, implantation began during the ﬁrst days of November, and a week later the erosion of the tubal wall resulted in a very slight hemorrhage, sufficient, however, to produce the ﬁrst attack of pain and fainting.
Fig. 1. Dorland’s embryo. Two views of the fresh tube, about natural size.
When the tube was removed a.nd opened the ovum slipped out through the incision, for it had been loosened by the hemorrhage and palpation. Only the tips of a few anchoring villi remained in the implantation—chamber which had been excavated in the tubal wall. There are as yet no data as to the appearance of the normal implantation—site at three weeks, and it is therefore impossible to say how far it departs from the normal in this case. As Mall (1915) stated for all of his cases, there is no si,g'.n.‘o_'f an-y deer’-dual tissue. Some regions of the implantation-site show a round—cell inﬁltration; in others polymorphs predominate, a.nd large mononuelear elements also appear usually containing pigment which is probably derived from ingested blood. The villi are similar in appearance to those of ova aborted from the uterus at this stage of development. There is no clear evidence of any phagocytosis of maternal blood-elements by the syncytium of the villi To judge from the free hand drawing of the fresh specimen (Fig. 1), the chorionic vesicle (ovum) measured eight by twelve millimeters. Its dimensions as determined from the sections are 8 x 6 X 4 mm.; the difference between the two sets of measurements represents collapse and shrinkage resulting from dehydrating and imbedding in colloidin. The chorion is rather smaller than would be expected from the stage of development reached by the embryo which had at least ﬁfteen somites. This may be judged from the following measurements of somewhat younger ova recorded in the literature.
Table I DESIGNATION CHORION WITH LENGTH NUMBER OF OF EMBRY0 VILLI OF EMBRYO Histological AUTHORITY
Mall embryo 391 .1(J'x14x12' mm. 2 mm. 8 Dandy, 1910
H87 U. of 18x113x10.8 mm. 2 mm. 8 Evans & Bartelmez_, Chicago 0011. 1917
Etern0d’S 16.3x14x12 mm. 2.12 mm. 9 Eternod, 1896 and embryo ‘DuGa’ V 1899
H8 U. of 21.3x18x9.4 3.3 mm. 14 Bartelmez Chicago Coll. (unpublished)
All of these ova came from abortions which had probably been mechanically induced, the embryos are normal and the measurements of the chorion are very probably typical of normally implanted ova at this stage of development. It is signiﬁcant that the chorion of the nine somite embryo “H 98”, described by Wilson (1914, p. 344 ss.), is also exceptionally small, as it measured 9x8x5 mm. including. the villi whilst still in formol. Now this embryo shows the same pronounced type of dorsal ﬂexure which our specimen exhibits. It came from an abortion, “causation undetermined.” Since this specimen of Wilson ’s had been implanted in the uterus it is not possible to attribute the small size of tubal ova to mechanical pressure inhibiting growth. The real difficulty is probably in the abnormal food-supply. This is clearly indicated by the almost invariable irregularity in distribution of the villi which characterizes ectopic pregnancies. In these cases there are large areas of chorion with few or no villi (of. Figs. 1 and 2). In older specimens there- is evidence of degeneration, as Mall (1915-) reported, but. in our case it is more probable that few secondary villi developed. There is a small group of them where the belly-stalk (pd.a-lad.) becomes continuous with the chorion. At the opposite pole there is a large group which shows well in Fig. 2 (mil). Here alone the villi are crowded together in the manner typical of a chorion frondosum. These villi were not apparent in the fresh specimen because they were closely applied to the wall of the tube. The longest villi measure 1.4 mm. in the sections and their structure is typical for this period of development. There are three layers; the mesenehymal core, the Langhans cells (cytotrophoblest) and the outer syncytium. The mesenehymal core is being vascularized. It is covered by a single continuous layer of cytotrophoblast which in turn is usually separated from the intervillous space by a continuous sheet of protoplasm with nuclei imbedded in it, m'z., the syncytium. At the ends of certain villi-——tl1ose, in fact, which served to anchor the ovum to the wall of the implantation-chamber———there a.re large masses of troph-oblastic cells with distinct ce1l—bounda.ries. All such masses a.re not necessarily in contact with maternal tissue. When they extend out into the intervillous space and in sections appear as detached masses they present the appearance of cell-islands and have been described as such (cf. Grosser, in Keibel and Mall, “Manual of Embryology,” 1911).
Embryologic Findings on Dorlann’s Specimen
The tube with the ovum attached was imbedded in celloi-din. The sections vary in thickness from about twelve to twenty-ﬁve miera and unfortunately all of the sections through the embryo itself were not preserved. I.t is accordingly impossible to give a complete description of the embryo and much of the interpretation is based on a detailed knowledge of the anatomy of other human embryos in about the same stage of development.
Figs. 2, 3, and 4., give a good general idea of the appearance of the embryo. It was out as nearly in the sagittal plane as it could be in View of the slight spiral twist of the long axis.
Fig. 2. A photomicrograph of the wall of the tube and the ovum which had been expressed from the tube after the removal of the latter. Magniﬁed seven diameters. Emb., embryo; lum., lumen of tube ﬁlled with exudate and blood; pd. abd., belly stalk; m'l., chorionio villi.
The outstanding feature of the external form is the sharp dorsalﬂexure at the level of the fourth pair of mesodermic somites (cf. Fig. 5). In this respect it resembles the nine somite embryo described by Wilson (1914, Figs. 5 and 6). This ﬂexure cannot be regarded as normal since it does not occur in perfectly preserved specimens obtained under the most favorable circumstances. As has been pointed out, the chorion in W'ilson’s embryo was also _exceptionally'sma1l.
The embryo, measured in the sections from tip t-o tip is 1.55 mm. long. For comparison with those embryos in which the dorsal ﬂexure is not present it is necessary to measure it as if it were straightened out. This length is 2.8 mm., and agrees. Very well with Pfanuenstiel III which was 2.6 mm. long before sectioning. Figures 3 and 4, are made from photomicrographs of the two sections nearest the midline, and Fig. 5 is a composite d1'a-u-“i'11-g of the salient features of the sections of the one lateral half which is completely represented in the series with the exception of the nervous system.
Figs. 3 and 4. Photomicrographs of sections 4 and 5 respectively, through Dorland’s embryo. X 45 diameters. Am., amnion; Cr. n.eur., neural crest; dien., diencephalon; gang. ac. fa:c., ganglion acousticofaciale; int. caud., hind gut; tin. pa-., primitive streak; mm. CL, cloacal membrane; mem. Mm, pharyngeal membrane; mg., magma; M2. 41., anterior neuropore; Mp. 39., posterior ne-uropore; ph., pharynx; pd. abd., belly stalk; 11. int. p., posterior intestinal portal; rmbc., hindbrair}; sac. m't., yolk sac; than, thyroid evagination; vent., ventricular loop of heart; -yes. opt, opt1c Vesicle; ‘vex. ot., otic vesicle.
The nervous" system is in the form of a tube open both at the rostral and caudal ends. The ante1'ior ileuropore appears in Figs. 3 and 5, (‘ll-p.61-.) where it is seen to extend at least as far back as the optic: Vesicles (-ves.0pt.). The latter were out in the horizontal plane owing to the spiral twisting of the embryo ’s long axis. They were in contact with the overlying ee.tode.1-in, as inay be seen in 3. This is a. rnatt-er of pai'tieul.a.r i.nterest because this relotrion has lice-n __f'o-end «in only one other h=zmm:n: cm-bryo (ﬂattelanee, 1922’, No. 470, Carne,o;ie Coll.) a.n<l_ was not present in any of the specimens studied by Bach und Seefelder (1911). The lens will subsequently arise from this overlying eetoderm but as yet there is no indication of a l_ens-thickening. It is at this time, doubtless, that the eet-oderm receives the stiinulus for lens-produetioii which the optic vesicle can transmit to any region of the skin, as the striking experiments on transplanting the optic Vesicle in the lower vertebrates have clearly shown.
The enlargement. immediately caudal to the optic vesicles is to- be interpreted as part of the dieneeplialon (dt€'?l). Behind it is a gap occupied by the I11ldl'.)1'21‘_i11
Fig. 5. A composite drawing made from projections with the Edinger apparatus of sections 4, S, 6, and 7 through Dorlancl‘s embryo, reduced to 66 diameters in reproduction. AIL, allantois; am, amnion; I3. ao., bulbus aortae; ch.-., notoohord; cr. n.emf., neural crest; eno,’., endocardium; gang. ac. fac., ganglion acoustico-facials; int. cau.d., hind gut; 11311. gm, primitive streak; ‘mam c!., cloacal membrane; mam. pk... oral membrane; up. a., anterior neuropore; pd. aboi, belly stalk; gr. as:-it. a., anterior intestinal portal; rmb.c.. hindbrain; sac. wit, yolk sac; sin. ':.'en., sinus venosus; tmz, thyroid evagination; vet:-., ventricular loop; ares. o3‘It._, optic vesicle; ‘I.'£’S. ot., otic vesicle. '
or mesenee.pl1a.lo1-1. W'l'll.Cll was lost in the sections. Its position is n1.a.rked by ‘ahe cranial ﬂexnre (ﬂex. cr.). The rostral end of the hindbrain 01' rhornbeneephalon (r-mbc.) appears in Fig. 4, with a portion of the neural crest (0-rm-) arising from it. Part of this eniigi-ating mass of cells probably enters into the trigeminal. ganglion. Opposite the lower end of this part of the hindbrain, the outer or skin ectoderm on either side is tliickened and forms the walls of a shallow" pit (oes.ot.). That is to say, this diﬁerentiatod patch of eetoderm is beginning to invaginate. We have here an early stage in the development of the otic Vesicle from which the membranous labyrinth arises.
At the caudal end the neural tube has not yet closed. The caudal neuropore can he recognized in -Fig. 3, and is indicated in Fig. 5 "(np.p.). Beyond this the neural folds merge into the primitive streak (Zia. pr.) which extends around the caudal end of the embryo and is continuous with the anal plate. This thickening of the ectoderm is the outer component of the eloacal membrane (me-m. cl.).
As the embryo is still for the most part sprea.d out on the yolk—sac (sac. 1:-it.) , the greater part’ of the gut is still in open communication with tl1e ca.vity of the yolk-sac. The fore-gut has closed as far back as the primordium of the liver. Rostrally there is a well-marked oral sinus (sin. or.) separated from the pharyngeal cavity by a thick oral membrane (-in-em-. pie.) in which the ectodernial and entodermal moieties are perfectly distinct. A minute spur of entoderm extends rostrally to the oral membrane indicating the presence of the preoral gut or pouch of -Seesel. These relations may be seen in Figs. 3 and 5. Behind the Oral n1e111b.I'a-Ile the ﬂoor of the pharynx may be seen extending into the pericardial cavity as a shallo-W diverticulum with thickened walls. This is probably the anlage of the thyroid gland (tlnz), for it lies just c.audal to the level of the ﬁrst visceral pouch. Since this evagination appears as a tliick-walled tube in the slightly younger embryos described by Wallin (1913) and Low (1908) it is probable that most of it was in the sections of our specimen which were lost. In Fig. 5, it will be seen that the fore-gut turns abruptly behind the tliyroid anlage and appears as a straight tube with a narrow lumen opening below into the cavity of the yolk-sac (sac. r-it.) at the anterior intestinal portal (p.-ism‘-.a.). Owing to the marked dorsal ﬂexure this part of the fore~gut is at right angles to the mid-gut which has not yet separated from the yolk-sac. Accordingly, the rostral wall of the tube is the floor, the caudal wall the roof, of the gut which has been separated from the yolk-sac by the caudally directed progress of the head—fold. From the conditions described by Low (1908) and Wallin (1913) in their specimens we should expect the rostral (really, ventral) wall of the gut in the region of the anterior intestinal portal to be thickened. as the anlagc of the liver. Such an hepatic thickening can be made out only with great difficulty in our embryo.
The sections in which the posterior intestinal portal appeared were lost but the section reproduced in Fig. 3, is obviously through the side of this portal (1). «Int. 19.). This section shows also a part of the diverticulum of the liind-gut which extends out into the be11y—stalk and represents all there is in man of the entoderm of the allaniois. Its position is indicated in Fig. 5, (a.Z'Z.). Figs. 3 and 5 show the cloacal membrane (mam. 01.) clearly
The composite drawing -of most of the sections of one side of the embryo which is reproduced in Fig. 5 shows all of the somites of that side projected on a single plane. There appear to be ﬁftcc-n. fully constricted oﬁ from the segmental plate. The ﬁrst is rudimentary, the second to eighth are longer dorso-ventrally than they are in rostro—caudal extent and have the dermatomes differentiating. The last seven are more nearly square in section as may be judged from Fig. 4, Plate, and have enlarged myocoels. In number of somites this embryo agrees with the specimens of Giglio-Tos (1902) and Tandler (1911, “Hal 2”). Only certain details of the nervous system of the former have been published and the description of the heart is all that has as yet appeared concerning the latter, so no detailed comparison is possible.
The heart is not unlike that of “Pfannenstiel III” as modeled and described by Low (1908) and that of “Hal 2” ﬁgured by Tandler in 1911, (Figs. 374-376). These two embryos differ in only one particular, namely, as to Whether the primordiurn of the atrium is single or double. It is impossible to say which is the case in our specimens. In the seventh section of the series, the bulbus aortae, ventricular loop, atrium and part of the sinus venosus extending into the septum transversum can be recognized and have been drawn into Fig. 5.
From what has been said it ma.y be concluded that this embryo is closer to Pfannenstiel “III” than any other human embryo of which we have an adequate description. The optic vesicles are distinctly farther along in development than in that specimen and there is one more pair of somitcs; but on the other hand the gut seems less differentiated. The heart and otic plate agree very well as to their development in both embryos. There is no detailed description in the literature of any specimen intermediate between these two a.nd the twins with 17 to 19 somites reported by Watts (1915).
A Comparative Clinical Study of a Group of Early Ectopic Pregnancies
As would be expected, most of the early embryos have been found in the uterine cavity. Caturani (1914) states that “the most accurate study of the literature shows that if the early uterine ova are few, the early tubal are extremely rare.” He adds, however, that “the earlier the age of the ovum (tubal) the more reliable the data, as compared with those offered by early uterine ova.”
There is a small group of the early tubal pregnancies with which it will be necessary to compare the clinical and histologic ﬁndings of the present case in order to satisfactorily determine their relationship. This group will not include the pathologie ova of Mall, nor his youngest normal ovum which had attainedto the size of 4 mm., thereby being removed from the class to which my embryo belongs.
There remain for consideration, then, only the cases of S. W. Band ler (1912), M. Penkert (1911), F. A. Stahl (1902), M. Caturani (1914) and R. W. Johnstone (1914), which in their clinical manifestations and histologic ﬁndings approximate those of my own case.
The Ova of Bandler and Stahl
Band1er’s case was reported in 1912 as “the earliest ‘recorded c.ase of ectopic gestation.” However, no embryo was discovered in the ovum, which, circular in outline and attached to the upper wall of the tube, measured 3.75x3.5x2 mm. While these ovular dimensions are materially smaller than those of the present ovum, which measured 8x6x4 mm., the absence of the embryo would make it impossible to determine the age of the gestation and would necessitate the grouping of this specimen among the pathologic ova. Moreover, the macroscopic appearance of the affected tubes in the two cases would militate strongly in favor of the younger age of my embryo, although the clinical histories of the cases are almost identical.
Bandler’s patient was ‘married two months and complained for a few days after her last menstruation of severe crampdike pains in the right side. There was, however, no fainting spell. On operation, the right tube presented a "purple and congested appearance, and the ovary of that side was enlarged to about three times the normal size and contained a hemorrhagic mass about the size of a walnut. These pathologic ﬁndings di"‘er materially from the present case in which a healthy appearance of all the organs was noted. The specimen removed by Stahl in 1898, which he judged to be of about the second to the third week in age, but in the description of which no reference is made to the presence of an embryo, must also be grouped among the pathologic ova. The gestation was of the ampullary type of tubal pregnancy, the sac lying within the ﬁmbriated extremity of the right tube. The diameter of the ovule was 7 mm.
Caturani, in 1914, reported a tubal gestation which, he claimed was not more advanced than three weeks, thus antedating the youngest tubal ovum of Couvelaire, which was 4 weeks old.
Caturani’s patient was 31 years of a.ge, and had one child 3 years old. The last menstruation was January 15-20, 1912. On February 17, she was seized with severe abdominal and pelvic pain attended with syncope and a slight show of dark—colored blood. Operation revealed a moderate quantity of free blood in the abdominal cavity, but no clots. A slight punctiform rupture was found in the upper part of the isthmic portion of the left tube close to the uterine end. A corpus luteum of pregnancy existed in the left ovary. N 0 embryonic area was found, probably, as Caturani states, “due to trophic disturbances, as is borne out by the relative disproportion between the blastocystic formation and evolution of villi.” It should be remembered, however, that it is possible for a normal development of villi to take place in the absence of the embryo. The ﬁndings thus recorded necessitate the gtrouping of this specimen among the pathologic ova.
Penkert’s specimen was removed from a woman 32 years of age, who had been sterile for two a.nd a half years. Her menses had always been regular. The last menstruation occurred on March 6, and the flow was due again on April 3. She indulged in coitus on the night of April 3-4 and a few days later suffered severe abdominal pain, her menses having failed to appear. A physical examination showed the uterus to be enlarged and 1°-etropo-sed. There was a small elastic tumor the size of a child ’s head in the left side of the pelvis adherent to the surrounding structures ; also, in the right side of the pelvis near the uterus was a tumor the size of a pigeon’s egg. Laparotomy was performed under spinal anesthesia with tropocain. The left ovary showed a cystic tumor; on the right side was a pigeon-egg sized ovary with three cherry-sized cysts. The right tube was as thick as a little ﬁnger, bluish-red in color and adherent, and contained the gestation-sac already described.
In May, 1914, R. W. Johnstone, of England, reported a very early ovum embedded in the infundibulum 0-f the left tube, the recent corpus luteum being located in the right ovary. The specimen was accidentally discovered during a Gilliam operation for retroversio uteri. It was a case. of primary infundibular attachment, not a tubal abortion. The size of the ovum was 2.73x6x5.6 1nm.; it was ﬂattened and almost circular in outline, and about the Same size, Johnstone claimed, as the ova of Rossi Dorie and Eternod. The embryo measured 2.1x1.6 mm., and J ohnstone estimated its age at about twenty days.
As in my case, the tubal attachment showed no trace of true decidual reaction in the form of decidual cells; but there was a very obvious invasion of the trophodermic elements into the tubal walls, both cells and syncytial masses being found at some little distance from the surface. The entire stroma of the tube at this point was in a most chaotic "state of disarrangement,iwhich Johnstone attributed to the lack of the protective action of the decidual cells which were absent. The embryologic ﬁndings of this case and their relative stage of development as compa.red with my embryo have already been noted.
Determination of Embryonic Age
The question of paramount interest in the scientiﬁc study of early embryos concerns the age of the given case. Unfortunately, We have no accurate criteria by which We may exactly estimate this, since we know practically nothing concerning the relationship existing be— between the processes of ovulation, menstruation and fertilization. Could we but know the exact time of the meeting of the ovum and the fertilizing element this question would be settled for all cases. Even in those instances in which it is positively known that but one coitus has occurred, there will remain an indeﬁnite period of several days during which time fertilization may occur. Nevertheless, Teacher and Bryce (1908) consider single coitus a very important factor in determining the ovular age, and it must be admitted that if but one coitus is positively known to haveioccurred the question of age has been narrowed down to a limited number of days. Then arise the perplexing questions of the actual place of meeting of the sexual elements, the rate at which both spermatozoon and ovum can travel in: the genital tract of the wonian, and the time during which an unfertilized egg can survive in the peritoneal cavity or fallopian tube; also, how long it is possible for the spermatozoon to retain its vitality and fertilizing power within the female genital tract. Still another element of uncertainty arises from our total ignorance of the exact time of expulsion of the ovum from the graaﬁan follicle. According to Leopold and Ravano (1907), in only 62 per cent of the cases is there a synchronism in the two phenomena of menstruation and ovulation; consequently, in 38 per cent of the cases ovulation may occur at any time other than during menstruation, and in these Women conception may occur then, the exact time of fertilization remaining a matter of great obscurity.
Von Spee and Minot believe that from seven to eight days elapsefrom the time of fertilization in the tube until implantation occurs in the uterine fundus. VVith this estimation as a Working basis it is possible, by noting the stage of development of the embryo proper, to arrive at a pretty accurate estimation of the age of the embryo. This will include the condition of the ehorion of the blastocyst, the presence or absence of a cellular layer‘ in the trophoblastic process, the presence or absence of an arrangement of the thin mesoblast in a dense layer around the chorionic Wall, and the presenceor absence of indentations of the wall (Teacher and Bryce).
The ingenious formula devised by Mall for determining embryonic age, which formula is expressed by the equation,
days -—-——- \/WW5 x length of embryo in millimeters,
while approximately accurate, will not give satisfactory results in every instance.
The interesting and outstanding features of this case are the following:
- I believe we have here the earliest recorded tubal pregnancy.
- The embryo, measuring but 1.55 mm., or, when the dorsal ﬂexure is straightened, 2.8 mm., and showing but 15 somites, groups itself among the smallest of all recorded embryos.
- The fallopian tube shows no sign of decidual tissue.
- A sharp dorsal ﬂexure in the outline of the embryo closely corresponds to that noted in Wilson’s embryo, is not a natural condition, and probably was produced by the contracted position of the ovum in the tube.
- The unusual relation of the optic vesicles, which are in contact with the overlying ectoderm. ,
- The very early stage in the development of the otic vesicle.
(To be contmcterl in the October issue.)
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Cite this page: Hill, M.A. (2019, October 19) Embryology Paper - Clinical and embryologic report of an extremely early tubal pregnancy. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Paper_-_Clinical_and_embryologic_report_of_an_extremely_early_tubal_pregnancy
- © Dr Mark Hill 2019, UNSW Embryology ISBN: 978 0 7334 2609 4 - UNSW CRICOS Provider Code No. 00098G