Abstract
Background: Ectopic pregnancies occur when the implantation of a fertilized ovum occurs outside the endometrial cavity. Such pregnancies occur in approximately 1.5% to 2.0% of all pregnancies and cause 6% of maternal deaths.
Objectives: To evaluate osteopathic structural examination (OSE) findings in patients with ectopic pregnancies of uncommon locations and to establish the utility of these findings in the diagnosis of these ectopic pregnancies.
Methods: In this prospective case series, a focused OSE was performed on each patient with an ectopic pregnancy at her initial presentation after the patient history but before other diagnostic or laboratory tests were performed and surgical treatment was initiated. Chapman reflex points (CRPs) were evaluated pre- and postoperatively. For comparison, patients who had otherwise normal first pregnancies, underwent elective postpartum bilateral tubal ligation, or had simple ovarian cysts were also included and received OSEs.
Results: Seven cases with ectopic pregnancies outside the fallopian tube were included. Two primary ovarian pregnancies and 1 heterotopic pregnancy (uterine and ovarian) had somatic dysfunction at the T10-T11 spinal levels and CRPs posterior for the ovary, 1 primary omental pregnancy with somatic dysfunction at the T9-T12 spinal levels and CRPs anterior and posterior for the ileum and jejunum, and 1 tubal pregnancy with somatic dysfunction at the T10-L1 spinal levels and CRPs anterior and posterior for the fallopian tube. Two cornual ectopic pregnancies were not associated with unique findings. These somatic dysfunctions and CRP findings appear to be distinct from those of comparison cases, including first pregnancies at any trimester, simple ovarian cysts, and elective bilateral tubal ligation.
Conclusion: The OSE findings demonstrated in these cases aided in the final diagnosis and thus can potentially prove helpful in cases of ovarian, tubal, and omental pregnancies to provide clues to abnormal ectopic pregnancy locations where diagnostic imaging results are insufficient or equivocal. Osteopathic structural examinations may allow osteopathic physicians to better prepare for treatment approaches, including surgery.
Keywords: Chapman reflex point, ectopic pregnancy, obstetrics, osteopathic structural examination
Ectopic pregnancy occurs in approximately 1.5% to 2.0% of all pregnancies
1 and is the cause of 6% of all maternal deaths.
2 While the majority of ectopic pregnancies commonly encountered in clinical practice are located within the fallopian tube with a mortality rate of 0.5% deaths per 100,000 live births, maternal mortality from ectopic pregnancies of uncommon locations is often much higher.
3 Maternal mortality mainly results from delay of diagnosis before rupture and resultant maternal hemorrhage. One half of 1% to almost 3% of ectopic pregnancies are implanted within the ovary,
3-5 1.3% are implanted within the abdominal cavity,
4 and 2% to 4% of all ectopic pregnancies are cornual (or interstitial) pregnancies.
4,6
In addition to conventional means of diagnosing a patient’s condition, many osteopathic physicians use palpatory findings of the musculoskeletal system to aid in the physical examination of their patients when conducting an osteopathic structural examination (OSE). These physical examination findings, collectively referred to as
somatic dysfunctions, the character and location of which depend on the specific organ or organs involved, aid in diagnosing and monitoring various disease states.
7 Although OSEs are often a part of osteopathic physicians’ initial diagnostic workup, OSE findings in cases of ectopic pregnancies of uncommon locations have yet to be described to the authors’ knowledge.
We present a case series of OSE findings in patients with ovarian, abdominal, heterotopic, and cornual ectopic pregnancy and compare them with cases of pathologic conditions of the uterus, fallopian tubes, and ovaries. Such OSE findings may enhance the initial diagnostic workup in emergent situations such as ectopic pregnancy and can potentially prove helpful in cases of ovarian, fallopian tube, and omental pregnancies, where diagnostic imaging results are typically insufficient and equivocal. Available osteopathic literature regarding somatic dysfunctions of the uterus, fallopian tubes, and ovaries are also reviewed.
Methods
We conducted a prospective observational study from July 2015 through February 2016. All appropriate institutional approvals and patient informed consents were obtained for this case series before patient evaluation. The inclusion criteria were suspicion of ectopic pregnancy either clinically or by ultrasonography without diagnosis before time of OSE. Exclusion criteria were patients with confirmed location of ectopic pregnancy before OSE was performed.
In the cases of ectopic pregnancy, a focused OSE was performed on each patient at her initial presentation after the patient history but before other diagnostic or laboratory tests were performed and surgical treatment was initiated. During the OSE, the patient was supine and the thoracic and lumbar spinal regions and sacrum were evaluated, in addition to relevant anatomical locations of Chapman reflex points (CRPs), which included the areas of the rib cage and pelvis. The CRPs, which are otherwise known as specific areas of lymphatic and venous congestion related to affected organs or pathologic process,
8 were evaluated pre- and postoperatively. Findings from the OSEs were recorded in the patients’ medical records.
For comparison purposes, cases of normal first pregnancy, elective postpartum bilateral tubal ligation, and simple ovarian cysts were also included. Patients with a normal first pregnancy underwent the same focused OSE and, so as not to confound the somatic dysfunction and CRP findings related to the uterus, fallopian tubes, or ovaries, included only those with a history of 1 pregnancy and no history of uterine or adnexal surgery. Findings from OSEs were recorded in the medical records. Patients seeking elective postpartum bilateral tubal ligation underwent a focused OSE preoperatively, immediately postoperatively, and 2 weeks postoperatively. “Immediately postoperatively” was defined as the period after the operation when the patient had completely recovered sensation from spinal anesthesia, so as not to inadvertently mask somatic dysfunctions. Patients with simple ovarian cysts underwent a focused OSE after identification of the cysts through transvaginal ultrasonography (TVUS). To eliminate varied results by different examiners, all OSEs were conducted by the same osteopathic physician (D.M.).
Osteopathic structural examination findings were correlated with findings on surgical exploration either through laparoscopy or laparotomy. Analysis was not performed beyond correlating preoperative OSE findings with surgical findings.
A literature search was performed using MEDLINE, PubMed, Google Scholar, and The Journal of the American Osteopathic Association from 1900 to 2015 to assess the literature regarding somatic dysfunctions of the uterus, fallopian tubes, and ovaries.
Report of Cases
Six cases were included in the case series of ectopic pregnancies in uncommon locations. An additional case of a tubal ectopic pregnancy was included to distinguish findings from those of uncommon locations. The somatic dysfunction findings presented in this cases series are summarized in
Table 1, and the CRPs and corresponding pathologic findings are described in
Table 2 and shown in the
Figure. Each case is described in the following paragraphs.
Table 2.
Chapman Reflex Points Among Patients With Ectopic Pregnancies and Corresponding Pathologic Findings: Case Series
| Case | Chapman Reflex Points | Refex Organ | Surgical Pathology | Pathologic Description | Final Diagnosis |
| 1 | None | None | Figure A | Fragments of uterine cornua, products of conception | Cornual ectopic pregnancy |
| 2 | None | None | Figure B | Fragments of uterine cornua, products of conception | Cornual ectopic pregnancy |
| 3 | Posteriorly at the tip of the transverse process of the fifth lumbar vertebra extending parallel with the crest of the ilium | Uterine fbroma | Figure C | Subserosal uterine fbroma | Heterotopic ovarian pregnancy |
| Posteriorly on the right between the 10th and 11th dorsal transverse space | Ovary (outer half) | Figure C | Ruptured primary ovarian pregnancy | |
| 4 | Posteriorly on the right between the 10th and 11th dorsal transverse space | Ovary (outer half) | Figure D | Fragments of ruptured primary ovarian pregnancy with resected ovarian tissue | Primary ovarian pregnancy |
| 5 | Posteriorly on the right between the 10th and 11th dorsal transverse space | Ovary (outer half) | Figure E | Fragments of ruptured primary ovarian pregnancy with resected ovarian tissue | Primary ovarian pregnancy |
| 6 | Anteriorly midway between the acetabulum and the sciatic notch and between the posterior superior iliac spine of the ilium and posteriorly at the spinous process of the fifth lumber vertebrae on the iliolumbar ligament | Fallopian tube | Figure F | Left fallopian tube and expulsed fetus | Tubal ectopic pregnancy |
| 7 | Anteriorly in the intercostal space between the 9th and 10th, and 10th and 11th ribs near the costochondral junction bilaterally, and posteriorly between the transverse processes of T9 and T10, and T10 and T11 midway between the spinous processes and the tips of the transverse processes | Jejunum and ileum | Figure G | Omentum, ruptured gestational sac, and products of conception | Primary omental pregnancy |
Table 2.
Chapman Reflex Points Among Patients With Ectopic Pregnancies and Corresponding Pathologic Findings: Case Series
| Case | Chapman Reflex Points | Refex Organ | Surgical Pathology | Pathologic Description | Final Diagnosis |
| 1 | None | None | Figure A | Fragments of uterine cornua, products of conception | Cornual ectopic pregnancy |
| 2 | None | None | Figure B | Fragments of uterine cornua, products of conception | Cornual ectopic pregnancy |
| 3 | Posteriorly at the tip of the transverse process of the fifth lumbar vertebra extending parallel with the crest of the ilium | Uterine fbroma | Figure C | Subserosal uterine fbroma | Heterotopic ovarian pregnancy |
| Posteriorly on the right between the 10th and 11th dorsal transverse space | Ovary (outer half) | Figure C | Ruptured primary ovarian pregnancy | |
| 4 | Posteriorly on the right between the 10th and 11th dorsal transverse space | Ovary (outer half) | Figure D | Fragments of ruptured primary ovarian pregnancy with resected ovarian tissue | Primary ovarian pregnancy |
| 5 | Posteriorly on the right between the 10th and 11th dorsal transverse space | Ovary (outer half) | Figure E | Fragments of ruptured primary ovarian pregnancy with resected ovarian tissue | Primary ovarian pregnancy |
| 6 | Anteriorly midway between the acetabulum and the sciatic notch and between the posterior superior iliac spine of the ilium and posteriorly at the spinous process of the fifth lumber vertebrae on the iliolumbar ligament | Fallopian tube | Figure F | Left fallopian tube and expulsed fetus | Tubal ectopic pregnancy |
| 7 | Anteriorly in the intercostal space between the 9th and 10th, and 10th and 11th ribs near the costochondral junction bilaterally, and posteriorly between the transverse processes of T9 and T10, and T10 and T11 midway between the spinous processes and the tips of the transverse processes | Jejunum and ileum | Figure G | Omentum, ruptured gestational sac, and products of conception | Primary omental pregnancy |
×
Case 1: Left Cornual Ectopic Pregnancy
Martingano et al
9 presented a case of an intact cornual ectopic pregnancy that ruptured intraoperatively. The patient was a 29-year-old woman, gravida 2, para 1, at 12 weeks gestational age by last menstrual period. She presented to the emergency department for evaluation of possible bicornuate uterus and ectopic pregnancy after routine ultrasonography. Her medical history was notable for 2 prior cesarean deliveries. The patient had no complaints of pain or discomfort at this time but did report vaginal bleeding with slight fetal movement. An OSE was performed on the thoracic and lumbar spine and the sacrum, which revealed hypertonic paraspinal muscles bilaterally at the T10-L2 spinal levels. No CRPs were identified. A pelvic TVUS revealed the presence of a gestational sac and positive fetal heart tones with an uncertain location, either within the left fallopian tube proximal to the uterus or to the left of the uterine fundus. A magnetic resonance (MR) image of the pelvis without contrast showed a 4.6-cm eccentrically located gestational sac to the left of the uterine fundus surrounded by an asymmetric thin mantle of myometrium consistent with an ectopic pregnancy of the cornua.
In the operating room, the contents were consistent with the MR image—a large ectopic pregnancy was located in the left cornua of the uterus with a very thin wall. Once the uterus was exposed, the left cornual wall was so thin that slight manipulation of the uterus caused rupture of the uterine wall and spontaneous expulsion of the fetus. The remaining products of conception were evacuated, a cornual wedge resection was performed, and the specimens were set aside for submission to the pathology department. The dermoid cyst was then removed. The rest of the pelvic structures appeared normal. The patient tolerated the remainder of the procedure well, and the rest of the hospital course was uneventful.
Case 2: Right Cornual Ectopic Pregnancy
A 33-year-old woman, gravida 1, para 0, at 12 weeks gestational age by last menstrual period presented to the emergency department by ambulance with complaints of syncope, vaginal bleeding, and severe abdominal pain. The patient denied any medical or surgical history. On evaluation, the patient was noted to be hypotensive (blood pressure around 90/60 mm Hg) and tachycardic (pulse rate, 135 beats/min). An OSE of the thoracic and lumbar spine and the sacrum revealed hypertonic paraspinal muscles bilaterally at the T10-L2 spinal levels. No CRPs were identified. A TVUS showed gross free fluid in the pelvis. Given this patient’s hemodynamic instability, emergent diagnostic laparotomy was performed via Pfannenstiel incision.
In the operating room, the abdomen was entered and the uterus exposed. An ectopic pregnancy was seen in the ruptured right cornua of the uterus. A cornual wedge resection and partial right salpingectomy were performed, and the remaining products of conception and approximately 1500 mL of hemoperitoneum were evacuated. The rest of the pelvic structures appeared normal. The patient tolerated the remainder of the procedure well, and the rest of the hospital course was uneventful.
Case 3: Heterotopic Ovarian Pregnancy
A 41-year-old woman, gravida 1, para 0, at 7 weeks gestational age by egg implantation date confirmed by early sonogram presented to the emergency department with sudden-onset abdominal pain. The patient reported that she initially tried over-the-counter antacids, simethicone, and milk of magnesia without relief. The patient denied shortness of breath, chest pain, nausea, vomiting, vaginal bleeding, or constipation. She reported a medical history of fibroid uterus, irritable bowel syndrome, infertility for 2 years, and 1 previous failed trial of in vitro fertilization. In this current pregnancy, the patient was attempting her second in vitro fertilization and taking progesterone suppositories twice per day and estradiol once daily. The patient’s surgical history included an ovarian cystectomy 10 years prior. On physical examination, the patient was tachycardic (pulse rate, 102 beats/min), normotensive (blood pressure, 126/81 mm Hg), afebrile, and without skin pallor. An abdominal examination demonstrated a tense, distended abdomen in all quadrants, with greater tenderness of the right lower quadrant than the left and rebound in both quadrants. Serum β-human chorionic gonadotropin level was 3951 mIU/mL.
An OSE of the thoracic and lumbar spines, sacrum, and lower extremities revealed hypertonic paraspinal muscles on the right at the T10-T11 spinal levels. Chapman reflex points were identified at the tip of the transverse process of the fifth lumbar vertebra extending parallel with the iliac crest and on the right between the 10th and 11th dorsal transverse space.
The patient was unable to tolerate a TVUS. An MR image revealed moderate fluid in the cul-de-sac with heterogeneity suggesting hemorrhagic components and an enlarged uterus with multiple fibroids. The largest fibroid was in the left side of the uterine body with a partial submucosal component, an exophytic subserosal fibroid was in the fundus, and smaller fibroids were seen within the uterine wall. An intrauterine pregnancy was identified. The left ovary was without abnormality, and the right ovary was difficult to visualize. A complete structure was identified in the right ovary. No normal appendix was seen. This patient subsequently underwent diagnostic laparoscopy.
After entering the abdomen, inspection included the appendix, liver, gallbladder, uterus, fallopian tubes, and ovaries. Hemoperitoneum was noted in the abdominal cavity, and evacuation of 700 mL of blood was performed. The patient’s right ovary had a hemorrhagic structure emanating from within. The subserosal fibroid seen on the MR image was additionally identified. Histologic analysis confirmed the presence of chorionic villi within the ovarian tissue. The rest of the visible abnormal tissue was removed from the ovary via ovarian wedge resection and cauterized to achieve adequate hemostasis. The fallopian tube and utero-ovarian ligament were not involved with the ectopic pregnancy. The rest of the abdominal structures appeared normal. The patient tolerated the procedure well and had an uneventful recovery.
Case 4: Primary Ovarian Pregnancy
A 17-year-old female adolescent, gravida 1, para 0, at 9 weeks gestational age by her last menstrual period presented to the emergency department by ambulance with complaints of vaginal bleeding and severe left lower quadrant pain. This patient’s medical history was notable for a copper intrauterine device (IUD) placed 3 years prior for contraception. The patient denied any surgical history. On physical examination, the patient was noted to be hypotensive (blood pressure around 90/50 mm Hg), afebrile, and tachycardic (pulse rate, 130 beats/min). An OSE was performed on the thoracic and lumbar spine and the sacrum, which revealed hypertonic paraspinal muscles on the left at the T10-T11 spinal levels. Chapman reflex points were identified on the right between the 10th and 11th dorsal transverse space. A TVUS was ordered, but the patient could not tolerate the examination. Given this patient’s clinical status, diagnostic laparoscopy was pursued.
In the operating room, the abdomen was entered and insufflated and a camera was inserted to view the pelvic contents. Approximately 2000 mL of hemoperitoneum was evacuated. Both fallopian tubes and the right ovary appeared normal. The left ovary demonstrated a ruptured ovarian pregnancy. An ovarian wedge resection was performed and electrocautery was used to obtain hemostasis in the remaining ovarian tissue. The fallopian tube and utero-ovarian ligament were identified and demonstrated to not be involved with the ectopic pregnancy. After the abdomen was closed, the copper IUD was removed. The remainder of the hospital course was uneventful.
Case 5: Primary Ovarian Pregnancy
A 22-year-old woman, gravida 1, para 0, at 11 weeks gestational age by last menstrual period presented to the emergency department by ambulance from an urgent care facility with complaints of severe right lower quadrant pain. Her medical history was unremarkable, and her surgical history was notable for an appendectomy 5 years prior. On physical examination, the patient was hypotensive (blood pressure, 120/70 mm Hg), afebrile, and tachycardic (pulse rate, 128 beats/min). An OSE of the thoracic and lumbar spine and the sacrum revealed hypertonic paraspinal muscles on the right at T10-T11 spinal levels and CRPs on the right between the 10th and 11th dorsal transverse space. The TVUS results from the patient’s previous care center suggested a ruptured tubal pregnancy. Given this patient’s clinical status, the decision was made to proceed to diagnostic laparoscopy.
In the operating room, the abdomen was entered and insufflated and a camera was inserted to view the pelvic contents. Approximately 2500 mL of hemoperitoneum was evacuated. Both fallopian tubes and the left ovary appeared normal. The right ovary demonstrated a ruptured ovarian pregnancy. An ovarian wedge resection was performed, and electrocautery was used to obtain hemostasis in the remaining ovarian tissue. The fallopian tube and utero-ovarian ligament were identified and demonstrated to not be involved with the ectopic pregnancy. The patient tolerated the remainder of the procedure well and the rest of the hospital course was uneventful.
Case 6: Tubal Ectopic Pregnancy
A 35-year-old woman, gravida 3, para 2, at 10 weeks gestational age by last menstrual period presented to the emergency department with complaints of vaginal bleeding and severe left lower quadrant pain. The patient’s medical history was notable for a copper IUD placement 3 years prior for contraception. The patient’s surgical history was significant for 2 prior cesarean deliveries. On physical examination, this patient was tachycardic (pulse rate, 110 beats/min), normotensive (blood pressure, 121/85 mm Hg), afebrile, and without skin pallor. An OSE of the thoracic and lumbar spines and sacrum revealed hypertonic paraspinal muscles on the left at the T10-L1 spinal levels. Chapman reflex points were identified midway between the acetabulum and the sciatic notch and between the posterior superior iliac spine of the ilium and at the spinous process of the fifth lumbar vertebra on the iliolumbar ligament. Images from TVUS revealed a moderate to large amount of complex fluid in the pelvis representing hemoperitoneum, an IUD in the endometrial cavity, and a ring-like structure with surrounding vascularity in the right ovary suggestive of a ruptured ectopic pregnancy. Given these findings, diagnostic laparoscopy was pursued.
In the operating room, the abdomen was entered and insufflated and a camera was inserted to view the pelvic contents. Approximately 100 mL of hemoperitoneum was evacuated. The uterus, right fallopian tube, and both ovaries appeared normal. A ruptured left fallopian tube was identified and the entire fallopian tube was removed. After hemostasis was achieved, the abdomen was exited and the sites closed. The copper IUD was then removed. The patient tolerated the remainder of the procedure well and the rest of the hospital course was uneventful.
Case 7: Primary Omental Pregnancy
Martingano et al
10 presented a case of a primary omental pregnancy that mimicked ovarian implantation: a 23-year-old woman, gravida 3, para 2, at 9 weeks gestational age by last menstrual period presented to the emergency department with complaints of severe abdominal pain for the past 3 hours. She denied vaginal bleeding, nausea, and vomiting. Vital signs at the time of presentation were stable (blood pressure, 117/82 mm Hg; pulse rate, 88 beats/min); however, physical examination revealed diffuse abdominal tenderness, guarding, and signs of acute abdomen with increasing lethargy. An OSE of the thoracic and lumbar spines, rib cage, and sacrum revealed hypertonic paraspinal muscles bilaterally at the T9-T12 spinal levels. Chapman reflex points were identified anteriorly in the intercostal space between the 9th and 10th and the 10th and 11th ribs near the costochondral junction bilaterally, as well as posteriorly between the transverse processes of T9 and T10 and T10 and T11 midway between the spinous processes and the tips of the transverse processes.
A TVUS image revealed an endometrial stripe of 8 mm, a large amount of complex fluid with internal echoes around the uterus and both ovaries (most likely representing hemoperitoneum), as well as a 0.5-cm left adnexal cystic structure with focal increased vascularity. An ectopic pregnancy of the left fallopian tube was suspected. Findings were highly suggestive of a ruptured ectopic pregnancy, and the patient was taken to the operating room for an emergent laparotomy.
Intraoperative findings were notable for 1500 mL of hemoperitoneum. Examination revealed a normal uterus with intact ovaries, ligaments, and fallopian tubes. Further inspection of the abdomen revealed a brownish-red encapsulated soft nodular tissue easily palpated and clearly seen on the left side of the omentum. The gestational sac was identified with surrounding blood clots, and a left partial omentectomy was performed with a wide omental excision technique to avoid leaving trophoblastic tissue behind. Examination of the remaining contents of the pelvis and abdominal cavity revealed no presence of abnormal tissue. The histopathologic report revealed focally hemorrhagic fibroadipose tissue, reactive lymph nodes, and products of conception consisting of immature chorionic villi in the supporting tissue.
Cases of Normal First Pregnancy
Fifteen patients with normal first pregnancy underwent OSEs to identify any somatic dysfunctions or CRPs present (
Table 3). Five patients were in their first trimester of pregnancy, 5 in their second, and 5 in their third. Of the 15 patients, 3 had somatic dysfunctions and CRPs identified. The somatic dysfunctions identified were all present for pregnancies in the third trimester and corresponded to those of the uterus. The CRP that was identified in these cases was related to the broad ligament, which likely resulted from irritation caused by the term gravid uterus.
Table 3.
Patients With Normal First Pregnancies and Corresponding Somatic Dysfunction and CRPs: Case Series Comparisona
| Case | Patient Age, y | Gestational Age, wk | Medical History | Somatic Dysfunction | CRP |
| 1 | 22 | 9 | None | None | None |
| 2 | 31 | 12 | Appendectomy | None | None |
| 3 | 25 | 9 | None | None | None |
| 4 | 27 | 10 | Hypothyroidism | None | None |
| 5 | 41 | 8 | Asthma | None | None |
| 6 | 33 | 19 | Cholecystectomy | None | None |
| 7 | 17 | 24 | None | None | None |
| 8 | 22 | 20 | None | None | None |
| 9 | 26 | 22 | Hypothyroidism | None | None |
| 10 | 25 | 21 | GERD | None | None |
| 11 | 24 | 38 | None | T10-L2 | Broad Ligament (posterior) |
| 12 | 24 | 39 | None | T10-L2 | None |
| 13 | 18 | 41 | Migraine headaches | T10-L2 | Broad Ligament (posterior) |
| 14 | 34 | 40 | Tonsillectomy | T10-L2 | Broad Ligament (posterior) |
| 15 | 32 | 39 | None | T10-L2 | None |
Table 3.
Patients With Normal First Pregnancies and Corresponding Somatic Dysfunction and CRPs: Case Series Comparisona
| Case | Patient Age, y | Gestational Age, wk | Medical History | Somatic Dysfunction | CRP |
| 1 | 22 | 9 | None | None | None |
| 2 | 31 | 12 | Appendectomy | None | None |
| 3 | 25 | 9 | None | None | None |
| 4 | 27 | 10 | Hypothyroidism | None | None |
| 5 | 41 | 8 | Asthma | None | None |
| 6 | 33 | 19 | Cholecystectomy | None | None |
| 7 | 17 | 24 | None | None | None |
| 8 | 22 | 20 | None | None | None |
| 9 | 26 | 22 | Hypothyroidism | None | None |
| 10 | 25 | 21 | GERD | None | None |
| 11 | 24 | 38 | None | T10-L2 | Broad Ligament (posterior) |
| 12 | 24 | 39 | None | T10-L2 | None |
| 13 | 18 | 41 | Migraine headaches | T10-L2 | Broad Ligament (posterior) |
| 14 | 34 | 40 | Tonsillectomy | T10-L2 | Broad Ligament (posterior) |
| 15 | 32 | 39 | None | T10-L2 | None |
×
Cases of Elective Postpartum Bilateral Tubal Ligation
Fifteen patients seeking elective postpartum bilateral tubal ligation underwent OSEs to identify any somatic dysfunctions or CRPs present before, immediately after, and 2 weeks after the operation (
Table 4). Of the 15 patients, 4 demonstrated somatic dysfunctions and 1 demonstrated CRPs corresponding to the broad ligament preoperatively, 6 demonstrated somatic dysfunctions and 3 demonstrated CRPs immediately postoperatively, and none had somatic dysfunctions or CRPs at the 2-week postoperative visit. The patients found to have somatic dysfunctions after the operation all had segmental findings corresponding to the uterus, which is likely a result of their recent pregnancy. The 1 CRP identified corresponded to the broad ligament, which is also likely a result of the recent pregnancy and gravid uterus irritating the broad ligament. Immediately postoperatively, somatic dysfunctions and CRPs identified corresponded to the fallopian tubes. All preoperative and postoperative somatic dysfunction and CRP findings were not present at the 2-week follow-up.
Table 4.
Patients Undergoing Elective Postpartum Bilateral Tubal Ligation and Evaluation of Somatic Dysfunction: Case Series Comparisona
| | | | | Somatic Dysfunction |
| Case | Patient Age, y | Gestational Age, wk | GPAb | Obstetric History | Preoperative | Immediate Postoperative | 2 Weeks Postoperative |
| 1 | 33 | 37 | G4, P4, A0 | NSVD x 4 | None | None | None |
| 2 | 35 | 37 | G4, P3, A1 | NSVD x 3 SAB x 1 | None | T10-L1, fallopian tube (posterior) | None |
| 3 | 36 | 37 | G5, P5, A0 | NSVD x 5 | None | None | None |
| 4 | 24 | 37 | G3, P3, A0 | NSVD x 3 | None | None | None |
| 5 | 39 | 38 | G6, P4, A2 | NSVD x 4 SAB x 2 | None | T10-L1 | None |
| 6 | 34 | 38 | G4, P4, A0 | NSVD x 4 | None | T10-L1 | None |
| 7 | 29 | 39 | G5, P5, A0 | NSVD x 5 | T10-L2 | None | None |
| 8 | 29 | 39 | G5, P4, A1 | NSVD x 4 TOP x 1 | None | None | None |
| 9 | 36 | 39 | G6, P6, A0 | NSVD x 6 | T10-L2 | None | None |
| 10 | 22 | 39 | G3, P3, A0 | NSVD x 3 | None | T10-L1, fallopian tube (posterior) | None |
| 11 | 27 | 39 | G5, P3, A2 | NSVD x 3 SAB x 2 | None | T10-L1 | None |
| 12 | 29 | 39 | G4, P3, A1 | NSVD x 3 TOP x 1 | None | None | None |
| 13 | 26 | 39 | G3, P3, A0 | NSVD x 3 | T10-L2 | None | None |
| 14 | 31 | 39 | G5, P4, A1 | NSVD x 4 SAB x 1 | None | T10- L1, fallopian tube (posterior) | None |
| 15 | 40 | 40 | G7, P6, A1 | NSVD x 6 TOP x 1 | T10-L2, broad ligament (posterior) | None | None |
Table 4.
Patients Undergoing Elective Postpartum Bilateral Tubal Ligation and Evaluation of Somatic Dysfunction: Case Series Comparisona
| | | | | Somatic Dysfunction |
| Case | Patient Age, y | Gestational Age, wk | GPAb | Obstetric History | Preoperative | Immediate Postoperative | 2 Weeks Postoperative |
| 1 | 33 | 37 | G4, P4, A0 | NSVD x 4 | None | None | None |
| 2 | 35 | 37 | G4, P3, A1 | NSVD x 3 SAB x 1 | None | T10-L1, fallopian tube (posterior) | None |
| 3 | 36 | 37 | G5, P5, A0 | NSVD x 5 | None | None | None |
| 4 | 24 | 37 | G3, P3, A0 | NSVD x 3 | None | None | None |
| 5 | 39 | 38 | G6, P4, A2 | NSVD x 4 SAB x 2 | None | T10-L1 | None |
| 6 | 34 | 38 | G4, P4, A0 | NSVD x 4 | None | T10-L1 | None |
| 7 | 29 | 39 | G5, P5, A0 | NSVD x 5 | T10-L2 | None | None |
| 8 | 29 | 39 | G5, P4, A1 | NSVD x 4 TOP x 1 | None | None | None |
| 9 | 36 | 39 | G6, P6, A0 | NSVD x 6 | T10-L2 | None | None |
| 10 | 22 | 39 | G3, P3, A0 | NSVD x 3 | None | T10-L1, fallopian tube (posterior) | None |
| 11 | 27 | 39 | G5, P3, A2 | NSVD x 3 SAB x 2 | None | T10-L1 | None |
| 12 | 29 | 39 | G4, P3, A1 | NSVD x 3 TOP x 1 | None | None | None |
| 13 | 26 | 39 | G3, P3, A0 | NSVD x 3 | T10-L2 | None | None |
| 14 | 31 | 39 | G5, P4, A1 | NSVD x 4 SAB x 1 | None | T10- L1, fallopian tube (posterior) | None |
| 15 | 40 | 40 | G7, P6, A1 | NSVD x 6 TOP x 1 | T10-L2, broad ligament (posterior) | None | None |
×
Cases of Simple Ovarian Cysts
Fifteen cases of patients with simple ovarian cysts underwent an OSE to identify any somatic dysfunctions and CRPs. Five patients had cysts on the left ovary, 5 on the right, and 5 bilaterally. Six patients presented with adnexal pain, and the others were asymptomatic. One patient with an 8-cm left simple ovarian cyst demonstrated somatic dysfunction (at the T10-T11 spinal levels) and a CRP (at the outer ovary, posterior). This patient presented with adnexal pain and had the largest ovarian cyst (8 cm) of the 15 patients evaluated (other patients, range 1.5-6 cm). Thus, it appears that VSRs and CRPs may be present only if these cysts reach a certain size or cause sufficient congestion.
Discussion
Osteopathic concepts in ectopic pregnancy have not been well studied, and currently no literature is available, to our knowledge, regarding CRPs in this setting. Moreover, these concepts have not been described in the setting of ectopic pregnancies outside the fallopian tubes. Additionally, somatic dysfunction and CRP findings in related conditions of the uterus, fallopian tubes, and ovaries are not well described. Smutny et al
7 state that OMT is contraindicated in ectopic pregnancies given that they are surgical emergencies. Nevertheless, this view does not preclude the use of an OSE as part of the initial physical examination and diagnostic approach.
Based on the literature search conducted, only 1 report describing somatic dysfunctions and ectopic pregnancy was identified. Woods
11 demonstrated somatic dysfunctions at T10-L1 in the case of a ruptured left tubal ectopic pregnancy. A review by Beal
12 revealed that somatic dysfunctions of the uterus, fallopian tubes, and ovaries have been found, typically at spinal levels T12-L1, T10-L1, and T9-L1, respectively, on average, with the more common locations being T10-L1, T10-L1, and T10-T11, respectively.
7,13-17 Based on Chapman’s work (as cited by Owens), ovarian cysts are recognized to cause CRPs:
Where ovarian cysts are present, if treatment is first started 15 days prior to the next menstrual period, employing short, decisive treatment at each visit, the reaction induced by this procedure, will sometimes cause the cyst to completely drain during the menstrual flow.8(pp76-77)
Burns
18-20 extensively researched and developed the concept of somatic dysfunction. Specifically relating to her work on the pelvic viscera, she studied animals in various stages of pregnancy and showed that electrical stimulation of the uterine cervix caused muscular contractions near the lumbosacral joint, whereas electrical stimulation of the body of the uterus caused contraction of the muscles near the second lumbar vertebra.
Regarding the cornual ectopic pregnancies, neither case was shown to be associated with CRPs, but both demonstrated somatic dysfunctions at T10-L2. For the heterotopic ovarian pregnancy, CRPs were identified posteriorly and were associated with uterine fibroma and the outer half of the ovary. Somatic dysfunctions were located at T10-T12 as well as at L1-L2, which likely represent the ovary and the uterus given the pathologic findings of both organs. Early pregnancy itself is unlikely to affect the somatic dysfunctions present because it was characteristically absent in the cases of an otherwise normal pregnancy of the first and second trimesters. In the third trimester, however, somatic dysfunctions and CRPs were identified at the uterus and broad ligament. Findings in the third trimester are unlikely to pose a confounding presentation of normal pregnancies and ectopic pregnancies, considering that ectopic pregnancies are usually restricted to the first trimester of pregnancy, during which no somatic dysfunctions or CRPs were demonstrated for normal first pregnancy in the current report, and they very rarely progress into the third trimester. For ovarian pregnancies, CRPs were identified posteriorly corresponding to the outer ovary. Regarding the omental pregnancy, CRPs were identified anteriorly and posteriorly, representing the ileum and jejunum irritation from the ectopic location on the omentum affecting the small intestine. It is likely that the hemoperitoneum itself was causing these CRPs because the previous cases presented also had hemoperitoneum and these CRPs were not additionally identified. In this case, somatic dysfunctions were present from T9-T12. Regarding the tubal pregnancy, CRPs were identified anteriorly and posteriorly corresponding to the fallopian tube. The somatic dysfunctions were found at T10-L1 and are consistent with previous studies.
From this case series, several conclusions can be drawn. Despite the variations of ectopic pregnancy locations, somatic dysfunctions were consistently identified at T10-L2, and this finding is absent when compared with otherwise normal first pregnancies in the first and second trimesters. For ectopic pregnancies of the ovary, it appears that when a CRP is identified, it usually corresponds to only the outer half of the ovary where the pregnancy had actually ruptured. It is unknown if an intact ovarian pregnancy of the inner half would have the same CRP identified. Hemoperitoneum on its own is not likely to be the main cause of CRPs or somatic dysfunctions given the variations of these components in the different cases presented and that all but 1 case had hemoperitoneum. Cornual ectopic pregnancies do not appear to elicit CRPs, unlike pregnancies of the fallopian tube, ovary, and omentum. The somatic dysfunction and CRP findings present in ectopic pregnancies of uncommon locations are not likely to be confounded by other conditions of the uterus, fallopian tubes, and ovaries as evidenced by the findings presented for otherwise normal pregnancies, elective bilateral tubal ligation, and simple ovarian cysts.
The OSE findings described in this case series are important because they enhance the initial diagnostic workup, which is essential in emergent situations like ectopic pregnancies, where prompt intervention is necessary and concrete diagnostic information is unavailable. The OSE findings demonstrated in these cases correctly aided in the final diagnosis and thus can potentially prove helpful in cases of ovarian, fallopian tube, and omental pregnancies to provide clues to ectopic pregnancy of uncommon locations where diagnostic imaging results are insufficient or equivocal. Such information allows the osteopathic physician to better prepare for treatment approaches, which in the cases of ruptured ectopic pregnancies is surgical.
Limitations
Because this report is a case series and thus has a limited sample size, the conclusions are limited. It is possible that the somatic dysfunctions identified resulted from somatovisceral interactions rather than somatic dysfunctions. This consideration is based on the work done by Johnston
21—namely, the somatic dysfunction and segmental alterations identified during the OSE were from somatic rather than visceral origin. It is possible that the somatic dysfunctions found on OSE at the thoracolumbar junction are somatosomatic findings related to associated dysfunctions found both superiorly and inferiorly in the thoracic, lumbar, and sacral spine regions. This cause is less likely in the cases of ectopic pregnancies, tubal ligations, and simple cysts but may be a factor in cases of term pregnancies where the gravid uterus causes great challenges to the lumbar spine and thoracic spine.
A randomized controlled trial of ectopic pregnancies and OSE findings would prove difficult given the emergent nature of the condition. Although CRPs were reevaluated and described, because of the urgent nature and emotional aftermath of ectopic pregnancies and other gynecologic operations, reassessing the patient with a full OSE proved to be difficult and consequently was not done. This is a gross limitation of this study. In future studies, it is imperative that complete, focused OSEs are used to reassess each patient after surgery to determine if the somatic dysfunctions located before surgery were indeed absent after the specific elements of the ectopic pregnancy were resected. This assessment would confirm that the somatic dysfunction of interest was directly related to the pathologic finding. Further studies are required to firmly establish reliable and reproducible OSE findings for these and related conditions.
Conclusion
While the majority of ectopic pregnancies commonly encountered in clinical practice are located within the fallopian tubes, ectopic pregnancies of uncommon locations can occur. The OSE findings described in this case series are important because they enhance the initial diagnostic workup, which is essential in emergent situations like ectopic pregnancies and can potentially prove helpful in cases of ovarian, fallopian tube, and omental pregnancies to provide clues to abnormal ectopic pregnancy locations where diagnostic imaging results are insufficient and often equivocal. Although OMT is contraindicated in ectopic pregnancies, it does not preclude the use of an OSE as part of the initial physical examination and diagnostic approach. Related disorders of the uterus, fallopian tubes, and ovaries, specifically in otherwise normal pregnancies, elective bilateral tubal ligation, and simple ovarian cysts, do not appear to consistently present with similar somatic dysfunctions and CRPs and thus are not likely to confound findings present in ectopic pregnancies of uncommon locations. Further studies are required to firmly establish reliable and reproducible OSE findings for these conditions in a larger population and among different pathologic conditions of the uterus, fallopian tubes, and ovaries.
References
Dialani V, Levine D. Ectopic pregnancy: a review.
Ultrasound Q. 2004;
20(3):105-117.
[CrossRef] [PubMed]Ectopic pregnancy—United States, 1990-1992.
MMWR Morb Mortal Wkly Rep. 1995;
44(3):46-48.
[PubMed]Chang J, Elam-Evans LD, Berg CJ, et al Pregnancy-related mortality surveillance—United States, 1991-1999.
MMWR Surveill Summ. 2003;
52(2):1-8.
[PubMed]Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases.
Hum Reprod. 2002;
17(12):3224-3230.
[CrossRef] [PubMed]Kraemer B, Kraemer E, Guengoer E, et al Ovarian ectopic pregnancy: diagnosis, treatment, correlation to Carnegie stage 16 and review based on a clinical case.
Fertil Steril. 2009;
92(1):392.e13-5. doi:10.1016/j.fertnstert.2009.04.014
[CrossRef] Fylstra DL. Ectopic pregnancy not within the (distal) fallopian tube: etiology, diagnosis, and treatment.
Am J Obstet Gynecol. 2012;
206(4):289-299. doi:10.1016/j.ajog.2011.10.857
[CrossRef] [PubMed]Smutny CJ, Hitchcock ME, Rivera-Martinez S. Gynecologic considerations. DiGiovanna EL, Schiowitz S, Dowling DJ. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:646-659.
Owens C. An Endocrine Interpretation of Chapman’s Reflexes. 1937. Reprinted, Carmel, CA: Academy of Applied Osteopathy; 1969.
Martingano D, Martingano FX. Intact cornual ectopic pregnancy and dermoid cyst with intraoperative rupture.
J Am Osteopath Assoc. 2016;
116(5):316-319. doi:10.7556/jaoa.2016.062
[CrossRef] [PubMed]Martingano D, Bogdanov A, Rybitskiy D, Martingano FX, Shahem S. Ruptured primary omental pregnancy mimicking adnexal implantation. J Am Osteopath Assoc. 2017;117(2):128-132. doi:10.7556/jaoa.2017.024
Woods ER. The viscerosomatic reflex in acute abdominal disorders.
J Am Osteopath Assoc. 1962;
62:239-242.
[PubMed]Beal MC. Viscerosomatic reflexes: a review.
J Am Osteopath Assoc. 1985;
85(12):786-801.
[PubMed]Standring S, ed. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. Elsevier Health Sciences; 2015.
House EL, Pansky B. A Functional Approach to Neuroanatomy. 2nd ed. New York, NY: McGraw-Hill; 1962.
Crosby EC, Humphry T, Biggerstaff DE. Fundamentals of Visceral Innervation. Springfield, IL: Charles C. Thomas; 1977.
White JC, SMithwick RH, Simeone FA. The Autonomic Nervous System. 3rd ed. New York, NY; MacMillan Co; 1952.
Bonica JJ. Autonomic innervation of the viscera in relation to nerve block.
Anesthesiology. 1968;
29(4):793-813.
[CrossRef] [PubMed]Burns L. The experimental demonstration of the osteopathic centers: the pelvic viscera. In: Studies in the Osteopathic Sciences: Basic Principles. Vol 1. Los Angeles, CA: The Occident Printery; 1907:256-257.
Burns L. Viscero-somatic and somato-visceral spinal reflexes. J Am Osteopath Assoc. 1907;7(2):51-60.
Burns L. Symposium on the A.T. Still Research Institute. J Am Osteopath Assoc. 1930;29:433-437.
Johnston WL. Osteopathic clinical aspects of somatovisceral/viscerosomatic interaction. In: The Central Connection: Somatovisceral Interaction: 1989 International Symposium. Sponsored by American Academy of Osteopathy, Indianapolis, IN. Athens, OH: University Classics Ltd; 1992:30-52.