Case Studies

Case 1 - Ectopic pregnancy

You are called to the emergency room to evaluate a 21-year-old woman in excruciating pain. She is sexually active, her partner uses condoms for contraception, and she is 6 weeks late for her period. Her blood pressure is 90/55 mmHg and her pulse is 115.

• 1. What is the quickest way to make a diagnosis based on this presentation?

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  Correct answer: This patient is becoming hemodynamically unstable and should receive urgent attention. Based on the brief history, the first priority should be to determine if she has an ectopic pregnancy. Other less likely possibilities include a ruptured ovarian hemorrhagic cyst, appendicitis, or a septic abortion with imminent shock. A bedside sonogram should be performed to look for hemoperitoneum and/or βhCG (βhuman chorionic gonadotropin) level sent. Although ectopic pregnancies are increasingly diagnosed before rupture, in this emergency case, a high clinical suspicion should prompt an immediate call to the operating room for expeditious surgical intervention. In the presence of a ruptured tubal pregnancy, it will be positive in >90% of cases if performed correctly. It is a useful, albeit infrequently used, diagnostic tool for this urgent situation. Maternal blood in the abdomen is initially able to clot in the same way that peripheral blood does. However, when an ectopic pregnancy has continued bleeding, this blood undergoes lysis. Retrieval of non-clotting blood obtained by culdocentesis will generally have a hematocrit >15% and confirm the diagnosis.

• 2. What is the etiology for most maternal deaths?

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  Correct answer: More than 90% of women who die experience rapid catastrophic blood loss, hemoperitoneum, shock, and ultimately cardiovascular collapse. Rarely, infections or anesthetic complications contribute to mortality. In about half of cases, significant delays by physicians or misdiagnosis by other medical personnel is at least partially responsible.

• 3. Are there any consistent symptoms of ectopic pregnancy?

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  Correct answer: Typically, early symptoms include an absence of menstrual bleeding and some description of spotting or irregular bleeding. Patients often seek medical attention at this point and are followed closely with sonograms and βhCG levels before the onset of dramatic symptoms. The pain of an ectopic pregnancy may be manifest in a variety of ways. Before rupture, it may only be a vague unilateral soreness or a colicky type of pain. After rupture, the severity of escalating pelvic pain depends on the rate of blood loss. Referred shoulder pain occurs in 25% as a result of diaphragmatic irritation from the hemoperitoneum.s

• 4. Why has there been a recent increase in the number of women diagnosed with ectopic pregnancy?

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  Correct answer: Several factors have resulted in the steep rise in the incidence of ectopic pregnancy. First, pelvic inflammatory disease (PID – see Chapter 8) is not only much more common than it was in the 1970s, but the management has gravitated toward conservative medical therapy or fertility-sparing surgery. As a result, more women with a prior episode of PID are at risk. Second, advances in diagnostic techniques (eg, transvaginal sonogram, βhCG) have resulted in earlier, and probably more frequent, diagnoses. Historically, tubal abortions were much more common without knowledge of the ectopic pregnancy location. In fact, about half of ectopic pregnancies are believed to undergo spontaneous tubal abortion without further sequelae. Third, the dramatic increase in infertility treatment and assisted reproductive technologies (ART – see Chapter 27) has contributed.

• 5. What are the surgical treatment options?

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  Correct answer: When a patient is diagnosed with an unruptured ectopic pregnancy, the treatment options include non-surgical management. If surgery is decided upon, then, if equipment is available, laparoscopy is preferred.

  • Salpingotomy (serosal defect in the fallopian tube is closed with sutures) and salpingostomy (serosal defect is left open to close by secondary intention – most common in the USA). These variations have about equal success in preserving fertility. In 5–10% of cases, postoperative methotrexate is required due to persistent trophoblast (placental) tissue at the ectopic site.
  • Partial or complete salpingectomy may be indicated when (1) childbearing is complete, (2) the patient has a prior history of an ectopic in the same fallopian tube, (3) there is significant damage to the inner lumen of the tube, or (4) if the health of the woman is significantly improved by more definitive management (e.g. large-volume blood loss).

  If the patient has a ruptured ectopic pregnancy and is hemodynamically stable, then surgery is required and laparoscopy is not necessarily contraindicated. The advantage of laparoscopy is a quicker postoperative recovery. The disadvantage is that in a woman with a hemoperitoneum it can take longer to clear the blood out, identify the ectopic, and treat it. The same type of surgery would be done regardless of whether a laparotomy is performed. In the presented case of a woman with a ruptured ectopic pregnancy who is hemodynamically unstable, a laparotomy should probably be performed and usually a (partial) salpingectomy. The removal of the damaged tube allows rapid control of bleeding and the best chance for continued hemostasis throughout the postoperative period.

• 6. What are potential problems of methotrexate medical management?

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  Correct answer: Treatment failure is the main worry with methotrexate therapy of an unruptured ectopic pregnancy. Every potential patient has a constellation of findings that factor into deciding whether it is safe to treat her medically. In general, the more advanced the gestation, the more likely it is to fail methotrexate and ultimately rupture without surgery. When evaluating a patient, at a minimum she must have an unruptured mass, be hemodynamically stable, and desire future fertility (see Chapter 5 for other relative and absolute indications and contraindications). Medical treatment is considered to have failed when the βhCG levels either increase or plateau by day 7 post-injection or when the tube ruptures. If medical therapy fails, rapid surgical intervention may be necessary. Patients treated with methotrexate must therefore be able to return for follow-up care.

  Methotrexate side effects are usually very mild in the typical, young, otherwise healthy patient. On occasion, significant nausea, stomatitis, diarrhea, dizziness, or pneumonitis can occur. During therapy, women should discontinue folic acid supplements (eg, prenatal vitamins) and avoid non-steroidal anti-inflammatory drugs.

  Treatment-related complications frequently include at least one episode of increased abdominal pain due to swelling of the tube. Typically it is a milder event than with tubal rupture, is of limited duration (1–2 days), and should not be associated with a surgical abdomen or hemodynamic instability. A sonogram can help confirm the absence of intra-abdominal blood.