Case Study on Chronic Ectopic Pregnancy

Diana is a married woman. She is 24 years old. She was seen in a rura hospital complaining of heavy prolonged bleeding for 5 days. 

She had missed two periods and said that she had passed clots. She was anaemic, her uterus was slightly enlarged, and her cervix was closed and still bleeding. 

A doctor diagnosed her as having an incomplete abortion, and did a ‘D &C’ (dilatation and curettage). 

He gave her iron tablets and discharged her, but she continued to bleed and to have low abdominal pain. 

So she went to another hospital where the doctor felt a tender mass on the left side of her uterus. He thought at first that she had an ectopic pregnancy, but he read the discharge card from the first hospital, which said that she had an incomplete abortion, and a ‘D and C’ was performed. So he was misled and diagnosed PID (pelvic inflammatory disease) with a tubo-ovarian abscess. He gave her antibiotics, and she went home. 

Nearly a month later she went to a private clinic run by a medical assistant. 

He correctly diagnosed an ectopic pregnancy, before even doing a vaginal examination, and referred her to a bigger facility, where diagnosis was confirmed with U/S, although a PDT (pregnancy diagnostic test) showed a negative result. 

Her haemoglobin was 4g/dl. Nevertheless, surgery was not delayed and she was transfused afterwards. 

At laparatomy she was done left salpingectomy. 

There are many lessons we can learn from the above case study: first of all, we must never be misled by other people’s clinical opinions. On the contrary, we must give our own independent diagnosis. Secondly, PID can actually produce symptoms which are very similar to those of a chronic ectopic pregnancy. 

Therefore we must always rule out ectopic pregnancy before discharging somebody with a diagnosis of PID: in fact, to miss an ectopic pregnancy could lead to the death of the patient. Thirdly, in up to 50% of the cases of ectopic, pregnancy test can be falsely negative: therefore we cannot base our diagnosis on PDT to rule out ectopic pregnancy. 

In ectopic pregnancy the cervix is normally closed and the vaginal bleeding is without clots. That cannot be taken as an absolute rule, because sometimes there are clots. Finally, the patient we described had some of the features of a subacute ectopic (severe anaemia), and some of a typical chronic ectopic pregnancy (a history of chronic pain); this shows that there is no sharp separation between those two conditions.

Bro Dr Beppe Gaido