Case study - Ectopic pregnancy

Ann (25 years of age) was seen in our hospital complaining of minimum PV (per vagina) bleeding for 5 days. 

Last December she had missed two periods and she said that she had passed clots. 

A doctor in another facility diagnosed her as having an incomplete abortion (unfortunately without performing a U/S), and did a ‘D and C’. 

He gave her iron tablets and discharged her, but she continued to bleed and have low abdominal pain. So she came to our hospital where the clinical officer in out-patient department felt a tender mass at both sides of her uterus. There was mild anemia at FHG (full hemogram) 

She was therefore referred to Dr Ogembo who did a U/S, making a provisional diagnosis of PID (pelvic inflammatory disease) with Lt ovarian cyst. 

Pregnancy test on urine was positive; so dr Ogembo referred the patient to Dr Gaido for second U/S and second opinion 

The ultrasonic test confirmed the presence of an ovarian cyst at the Lt of the uterus, but also showed an irregular, complex mass at the Rt of the organ and in the Douglas pouch. 

The opinion of Dr Gaido was that there was high possibility of being in front of a case of chronic ectopic pregnancy, maybe dating as from December and not properly diagnosed at the first admission. The ovarian cyst was considered to be innocent and possibly present for many years. 

After long discussion and considering the possibility of an acute bleeding at any time, Dr Gaido proposed urgent laparatomy. 

Dr Ogembo was more for a try with antibiotics before, but later agreed that it was better an explorative laparatomy “for nothing”, rather than leaving there for the night an ectopic pregnancy which could rupture at any time with high mortality rate. 

Blood group and cross matching was done and we entered theatre. 

The operation confirmed the presence of Rt chronic tubaric pregnancy and left ovarian cyst. Probably few minutes before the opening of peritoneum, the ectopic pregnancy ruptured, because we found a massive hemoperitoneum, and we had to transfuse the patient trans-operatively. Rt salpingectomy was done, while the cyst was marsupialized.

The patient is now recovering uneventfully in the ward.

•     LESSONS LEARNED THROUGH THIS CASE

•     (1) Don’t be misled by other people’s clinical opinions: probably this mother had already an ectopic in December and D/C was the wrong therapeutic choice.

•     (2) PID can produce symptoms which are very similar to those of a chronic ectopic pregnancy.

•     (3) This patient had some of the features of a subacute ectopic (anaemia), and some of a typical chronic ectopic pregnancy (a history of chronic pain); this shows that there is no sharp borderline between these two conditions.

•     Before you diagnose PID, stop and think – ‘Could this be a chronic ectopic?’: missing the diagnosis of ectopic pregnancy may be life threatening for the patient  

LEGENDA

D AND C=  dilatation and curettage (raschiamento uterino)

U/S= ultrasound (ecografia)

DR GAIDO

AND CLINICAL STAFF OF COTTOLENGO MISSION HOSPITAL CHAARIA