“Mini-ssippi Appendectomy:” On routine practice of coercive subtotal sterilization during surgical management of ectopic pregnancy

A 23-year-old with an ectopic pregnancy — one implanted outside the uterus, usually in the fallopian tube — presented for a second round of methotrexate injection since her pregnancy hormone levels were still increasing two weeks after her first dose. She had never had surgery before and was afraid of going to the operating room, mainly because she was worried about coming out of it missing one of her fallopian tubes. She was right to have that concern. At that point she was asymptomatic, so it was appropriate for continued medical management. Only, when I went to place the order in the electronic medical record, I noticed someone else had just given her IV hydromorphone (Dilaudid): a potent opioid. Why was this allegedly asymptomatic patient receiving such a powerful, potentially dangerous pain medicine…?

My resident returned to her bedside in the emergency department, confirming that she was now vomiting and writhing in agony. This was highly concerning for a ruptured ectopic, a surgical emergency which usually occurs when a tubal pregnancy grows too large to be contained by the delicate but vascular tube, causing it to burst, spilling blood into the peritoneal cavity. Blood irritates the lining of the abdomen, causing extreme pain. Blood loss due to ruptured ectopic pregnancy is also a major cause of pregnancy-related mortality. At this point, emergent surgery was indicated. She and her family initially resisted the change of plans, however her pain worsened, and she ultimately agreed to operative management, pleading with the resident to save her tube if at all possible.

I take hospital call from home, so the patient was already asleep and being positioned on the operating table when I arrived. “She didn’t want surgery,” the resident said as we scrubbed. “She really wanted to keep both her tubes, so I consented her for possible salpingostomy vs. salpingectomy:” either opening the tube, removing the pregnancy tissue and stopping any bleeding, or simply removing the bleeding, abnormal-pregnancy-containing tube itself. “She is aware that we will most likely take the affected tube,” she reassured me.

It’s always nerve-wracking the first time you do a surgery as an attending, the *responsible* party. This would not only be the first time I attempted a salpingostomy; I had only ever seen one once before, years ago during my second year of residency reproductive infertility rotation, on a patient who only had one tube remaining at the time. Of course, I had read about the procedure many times before, though it never seemed to come up… “Let’s just see what we’re dealing with before we make any decisions,” I reasoned aloud as we proceeded with the diagnostic laparoscopy: the gynecologist’s box of proverbial chocolates. Once inside, we confirmed that her right tube was distended, with blood oozing out the tube and collecting in her pelvis. This was the classic picture, a very familiar scene.

In general, I try to practice the golden rule of medicine: treating patients how I would want to be treated. Usually, as in this case, it means I would want my wishes respected and my all-things-considered interests to guide my surgeon’s hand. Turning the case over in my mind, I considered that proceeding directly to salpingectomy, per our typical practice, would be easier, quicker, and within the standard-of-care. However, it would not be consistent with the patient’s wishes for her own body and future fertility. She already had one ectopic pregnancy — also on the right side, previously treated successfully with methotrexate — and was thus at risk for recurrence, even more so if the “culpable” tube remained in situ. But, at 23, she also had many reproductive years ahead of her, and her chance of spontaneous intrauterine pregnancy (read: conceiving naturally, without reproductive assistance) would be higher with both tubes, even if one of them wasn’t perfect. What would happen if we take the right tube now and she has an ectopic on the left a few years later?

Though inexperienced with this procedure, I am very comfortable operating in the adnexa. I proposed to my resident that we attempt salpingostomy, with salpingectomy as plan B, but wanted her opinion, since she was my main surgical teammate and knew the patient best. “Well…this is her second ectopic on the right, I’m kinda ‘over’ that tube,” she replied, hesitant to deviate from routine. “Besides, in the past 4 years I’ve done 100s of salpingectomies but haven’t seen a single salpingostomy even attempted…” she inferred, “there must be some reason for that.” She was assuming that surgeons avoided the latter procedure because, based on their clinical experience, its risks outweighed its benefits for patients. I wasn’t so sure.

I walked her through my thought process. “Worse-case scenario, if we have difficulty, we proceed to salpingectomy, which we can perform swiftly and easily. The real downside to the patient from us attempting salpingostomy is potential loss of the very structure we would otherwise just remove.” She seemed convinced. Wanting to consider all angles, I mused, “Alternatively, if we run into bleeding, laparotomy is an option, since I’m confident we could obtain hemostasis via an open approach.” She balked, “that’s not worth it.” Truthfully, we did not know whether our patient would rather undergo a laparotomy to keep her tube or lose her tube to avoid a laparotomy. These sorts of value-based tradeoffs are best discussed preoperatively, though it’s not always possible to cover every contingency, and degree of nuance must be balanced against efficiency when a patient is in severe pain and actively bleeding.

So, we proceed with the salpingostomy. Guess what? It went totally fine, though it was certainly a more challenging procedure than salpingectomy, and there was definitely a moment when her steadily bleeding tube seemed to be laughing at my vain attempts at hemostasis. I remained calm and methodical, trouble shooting with various instruments and techniques until, little by little, the bleeding subsided. And then it stopped completely. We waited patiently and watched, but everything remained dry. The procedure was a success.

I was truly happy for the patient, and pretty satisfied with myself, I must admit. I was also still a bit uneasy, though the character had evolved from anxiety about this case to apprehension about what it meant for all the cases. I found myself wondering: does our profession have a default presumption of removing a vital, functional organ, not because it’s in patients’ best interests or consistent with their values, but simply because it’s easier?

It was nearly midnight when I left the OR to go update her family. Five concerned family members listened raptly as I explained that she was doing very well, that she was bleeding initially, which meant we made the right decision in proceeding with surgery, and that we were able to preserve her injured tube. I was not prepared for the outburst of joy, an outpouring of “Hallelujah!” “Praise the Lord,” and “thank you Jesus!” that suddenly filled the large, otherwise empty waiting room. The matriarch threw her arms in the air, and with a gleaming, nearly giddy smile, chirped “I just have to give you a hug!” I ran through what they could expect in terms of recovery, basic postop information, etc, and turned to walk towards my car. All the way down the hallway, I could hear them chatting excitedly with one another, celebrating that their loved one was not only safe, but whole.

This was a great outcome, but clearly not what they were expecting. To be fair, it wasn’t what I had expected to do. I wasn’t sure why exactly, since the procedure is within the standard of care, well within my skillset as a gynecologic surgeon, and seemed, at least in this case, unequivocally the right thing to do. Salpingectomy is not just easier for surgeons; making it our default approach to this common diagnosis shows a callous disregard for women’s bodily integrity and reproductive intentions, especially given the clear evidence that spontaneous intrauterine pregnancy rates are higher after salpingostomy. In the U.S. up to 2% of pregnancies are ectopic and roughly half are treated surgically. This affects A LOT of women.

By the time I got to my car, I was getting angry. From a dusty corner of my brain, I remembered reading a few years ago at least one major study demonstrating significant racial disparities in rate of salpingectomy vs. salpingostomy: black women were far more likely to have their tubes removed and white women to have tubal preservation. Default salpingectomy, especially insofar as there are racial differences in how women are treated, darkly echos coercive sterilization — a deeply disturbing practice which is known to have shamefully continued in the U.S. at least into the 2000s. In Medical Bondage, Dierdre Cooper Owens’ gives a troubling account of the history of American Gynecology as a racially biased and exploitative enterprise. She discusses the term, “Mississippi Appendectomy,” coined by Fannie Lou Hamer for the involuntary surgical sterilization, frequent perpetrated in the deep South, of socioeconomically, racially and intellectually “inferior” women. The horrible thought hit me: is presumed salpingectomy for ectopic a low-key “Mini-ssippi Appendectomy?”

Most gynecologic surgeons would be horrified by this allegation, as almost all are truly good people who work hard to care for women and generally mean well. And, of course, there is a lot of nuance I’m leaving out here. There are medical and surgical considerations, surgeon-level factors, insurance issues, social determinants of health, etc, all of which bear on the reasons one might perform a salpingectomy instead of a salpingostomy. However, we must admit there’s a pretty troubling record of surgically removing organs that people are better off keeping — tonsillectomy, appendectomy, oophorectomy, to name a few… As it turns out, more is not more. Yet again.

It’s crazy when you think about it… If someone had a non-cancerous renal mass that was bleeding, we wouldn’t automatically remove the kidney “because they have another one,” and we wouldn’t say, “hey, there’s always dialysis or transplant if that doesn’t work out.” Yet, when it comes to the surgical management of ectopic pregnancy, that is precisely our attitude. This is inappropriate on many levels, not least of all that most women in this country either do not have access to or may not want to use assisted reproductive technology. Moreover, in vitro fertilization itself carries risks that we’re too casually imposing on women’s hypothetical future fertility struggles.

We also must admit that we have a problem, specifically and uniquely manifested in Obstetrics & Gynecology, with implicit and explicit racial bias. It’s affecting mortality related to both pregnancy and cancer, and its impacting intentional childbearing from disparities in access to assisted reproduction, compounded, I suspect, by disparities in access to salpingostomy. One final thread I’d like to pull on is how stigma against women with sexually transmitted infections, the major modifiable risk factor for ectopic pregnancy, may be impacting our management of this condition. Are we surgically imposing an air of righteous comeuppance? Indeed, the first salpingostomy I saw was with a reproductive endocrinologist on a married white woman who was undergoing intrauterine insemination. The first one I performed was on an unmarried black woman with a history of chlamydia who wanted to keep both of her fallopian tubes, and with them the most open future for childbearing her body would allow.

In closing, I want to advocate for treating salpingostomy, not salpingectomy, as first-line treatment for women with ectopic pregnancy who desire future childbearing. They should be counseled appropriately, based on available evidence and shared-decision making regarding risks and benefits, which should be guided by patients’, not their surgeons’, best interests. This fits into the bigger picture in which surgical management of ectopic pregnancy should be treated as an opportunity to advance a woman’s own reproductive ‘vagenda’ — whether it be through preserving both tubes, removing both, placing an IUD, etc. At the very least, as a profession, we owe it to our patients to reflect on our own surgical counseling and practices, examining if we are treating our patients as we would truly wish for ourselves and our loved ones to be treated.

Marielle S. Gross, MD, MBE

Written by

OB/GYN Bioethicist — Focusing on how to leverage cutting-edge technology to promote quality, efficiency and justice in women’s healthcare @GYNOBioethicist

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