1. Demographics
♣ Name: J. R. M
♣ Hospital No.: 27123
♣ DOB & Age: 11/2/1985; 33 years
♣ Nationality: Filipino
♣ Blood Group: B+
♣ Date of Admission: 8.11.2018 at 9:23 p.m.
♣ Residency: Sharjah
♣ Occupation: Housewife
♣ Marital State: Married
2. Chief Complaint
A two months pregnant with abdominal pain that started today. The patient fainted in triage before vitals were checked and was taken to resuscitation room.
3. History
History of chief complaint
Jenilyn, a 33 years old female admitted to al Qassimi hospital in Sharjah after she presented alone to the emergency department complaining if palpitations and abdominal pain both started this morning. Her abdominal pain started suddenly this morning and is localized to the right side of the lower abdomen described as stabbing intermittent pain. The pain doesn’t radiate anywhere else and the patient says it’s exacerbated by sudden movements. She gave the pain a score of 6 out of 10 on the pain scale
The patient was seen in a private clinic yesterday where she had her B-HCG level checked and was told that it could be early pregnancy but if any pain occurred she has to go to the emergency department.
Review of Systems
Constitutional symptoms: abdominal pain, palpitations, tachycardia
Integumentary: She has a right laparoscopic scar. No history of skin rash or discoloration.
Cardiovascular: tachycardia, palpitations, no blue discoloration of nails or extremities
Gastrointestinal: history of abdominal pain of sudden onset started this morning. Pain is localized to the right side of the lower abdomen and doesn’t radiate anywhere else. No history of decreased appetite vomiting, diarrhea.
Genitourinary: no history of increased frequency of urination, change in urine color or abnormal smell. No hematuria or vaginal bleeding.
Obstetric History:
The patient is G3P0 +2 ectopic pregnancies. The first ectopic pregnancy occurred in 2015 on the right fallopian tube and was medically managed in AQH. The second ectopic pregnancy was in 2016 on the left side and a salpingectomy was performed in AQH as well.
The current pregnancy’s age is 6 weeks according to the last menstrual period that was on 26/09/2018. This pregnancy was spontaneous.
Gynecological History:
Patient had menarche at the age of 12 years. Since then her menstrual period was regular occurring every 30 days with menses lasting 5-6 days with normal blood flow accompanied with mild abdominal cramps. Her LMP was on the 26th of September 2018. She doesn’t have intermenstrual bleeding, other gynecological problems, or history of contraceptive use. She performed a pap twice until now one in 2015 and the second in 2016 after each pregnancy.
Past Medical History:
No significant medical history. Patient is healthy and has nor chronic illnesses such as diabetes or hypertension.
Past Surgical History:
1- medical management of ectopic pregnancy in 2015 on the right fallopian tube.
2- salpingectomy in 2016 on the left side.
Findings:
o Hematoperitoneum 1500cc with clots
o Left tubal pregnancy (intramural region with ruptured pregnancy); the tube was markedly distended and distorted
o Left tube ampular adherent to the sigma
o Right tube with inflammation changes adherent to the right ovary
Drug History:
No significant drug history of allergy to drugs, food, or any allergens.
Family History:
No significant family history
Social history:
o She smokes one cigarette per day for five years and doesn’t think about quitting.
o She doesn’t consume alcohol.
o Diet is normal and is mainly home cooked food.
o She used to exercise regular but stopped exercising since one year.
o Her husband doesn’t smoke
o She is not related to her husband, husband is abroad in vietnam
4. Upon Physical Examination
Vital Signs:
o Heart Rate: 93 bpm, regular rhythm
o Respiratory Rate: 18 br/min
o Blood pressure: 108/55 mmHg
o Temperature: 36.4 degrees
o SpO2: 98% on room air
• General Assessment: patient is conscious, alert, oriented. Well-hydrated, no acute distress.
• Abdomen: Abdomen is slightly distended and tender and there’s a laparotomy scar.
• Genitourinary Examination: Normal
• No significant abnormalities on systemic physical examination
5. Case Summary
J. R. M, a 33-year-old female presented to the ER with a one-day complaint of palpitation and abdominal pain that is non radiating, intermittent, localized to the RLQ and described as a stabbing pain that is aggravated by sudden movement. Her B-hCG was tested yesterday in a private clinic and the result was interpreted to be a possible early pregnancy. She has a history of 2 ectopic pregnancies that were managed in AQH. Her menstrual period is normal and regular and her LMP was on 26/09/2018. The patient is otherwise healthy and isn’t on any medications, has no other illnesses, significant family or social history.
6. Impression and Plan
Provisional diagnosis most probably is a recurrent right tubal ectopic pregnancy post laparotomy and left salpingectomy. Admit patient for laparoscopy. Explain need for SOS laparoscopy and laparotomy with right sided salpingectomy vs salphigiostomy in view of previous salpingectomy. Explain that if tube is removed; IVF will be the only option for the next pregnancy.
7. Investigations that must be done to confirm Dx
1. Laboratory
o CBC: Hb is 11.2
o ABO/Rh type
o Antibody screen gel
o BhCG quantitative
o Dialysis electrolyte and renal profile
o Liver function test
o Hepatitis B surface antigen
o TSH levels
o HIV screen
o PT & PTT
o Rapid plasma reagent
2. Ultrasound scan
o TAS and TVS done (offered and patient agreed), GE10.
o TVS done after emptying the urinary bladder (Foley’s catheter) on the bed.
o Moderate free fluid collection with blood clots seen in the right adnexa.
o Bowl loops seen floating posterior to uterine wall.
o Anteverted uterus, regular outer corners
o Visible, normal cervical canal and cervical length= 3.31 cm
o Myometrium is homogenous
o Endometrium appears regular and thickness is =12.19 mm
** No evidence of intrauterine gestational sac detected
o Both ovaries are visible
– right ovary looks normal in size and shape with small follicles; a well-defined rounded, vascular mass seen in the right adnexa measuring 1.44 cm into 1.89 cm suspected right ectopic pregnancy.
– left ovary is visible, ovary looks normal in size and shape with small follicles, suspected left corpus luteal cyst (2.49 cm into 2.81 cm). No evidence of left adnexal pathologies detected.
8. Differential Diagnoses
o Miscarriage
o Acute appendicitis
o Ovarian torsion
o Pelvic inflammatory disease
o Tubo-ovarian abscess
o Ruptured corpus luteal cyst or follicle
o Nephrolithiasis
o UTI
9. Treatment
10. Follow-up
o Discharge upon recovery and careful monitoring of vitals
o Recommend careful movement and exercise post-surgery
o Inform patient about ability to resume sexual intercourse in 4-6 weeks
o Give an appointment for outpatient clinic 4-6 weeks’ post discharge
Learning Objective: Ectopic Pregnancy
– Definition
An ectopic pregnancy is when a fertilized ovum embeds and develops outside of the uterine endometrial pit. The most well-known site in around 97% of the cases is the fallopian tube and specifically in the ampulla, then comes the ovary (3.2%) and the mid-region (1.3%). On the off chance that undiscovered or untreated ectopic pregnancy might promote to maternal demise because of burst of the implantation site leading to intraperitoneal bleeding.
– Risk Factors
– iatrogenic
– PID distorting the anatomy of fallopian tubes
– smoking
-chronic inflammation or genital infection
– use of intrauterine devices
-inutero diethylstilbestrol exposure of the mother
– prior fallopian tube surgery
– in vitro fertilization
– age <18 at first sexual intercourse
– black race
– age >35 at presentation.
– multiple sex partners
-Etiology
The underlying causes that lead to ectopic pregnancy are classified into two groups
1) a setting that hinder the passage of fertilized egg to the uterine cavity
2) a setting that prompt the premature and early implantation.
The successful transport of embryos within the uterine tube needs a carefully regulated and complicated interaction between the tube’s anatomical structure, epithelial tissue, tubal fluid, and contents.
This interaction ultimately generates a mechanical force of bodily peristalsis ciliary motion and the fluid flow in the fallopian tube in order to drive the embryo toward the cavity for implantation. This pathway is subject to pathologies at many various points that may ultimately manifest as extra-uterine pregnancy. Any issue regarding the migration of the ovum will most probably be related to abnormal anatomy. Abnormalities can be secondary to infection or chronic inflammation such as chronic salpingitis, salpingitis isthmica nodosa. It could also be due to amendments in molecular signaling between the oocyte and the implantation site may make an ectopic pregnancy more likely. Such as changes in cellular and extracellular matrix proteins like lectin, integrin, matrix-degrading cumulus, prostaglandins, growth factors, and cytokines.
As the ectopic grows, the outer layer of the fallopian tube stretches. This ultimately leads to tubal rupture and bleeding.
– Common key diagnostic factors
-abdominal pain and tenderness
-amenorrhea
-vaginal bleeding
-adnexal tenderness or mass
-hemodynamic instability, orthostatic hypotension
-urge to defecate
-referred shoulder pain
-Investigations
urine or serum pregnancy test +ve
high resolution transvaginal ultrasound (TVUS) no intrauterine pregnancy detected; ectopic pregnancy visualized
Transabdominal ultrasound no intrauterine pregnancy detected
Serial serum B-hCG <53% increase in level over 48 hours or plateau of level
-Differential Diagnosis
o Miscarriage
o Acute appendicitis
o Ovarian torsion Ovarian enlargement secondary to impaired venous and lymphatic drainage is the most common sonographic finding in ovarian torsion.
o Pelvic inflammatory disease
o Tubo-ovarian abscess
o Ruptured corpus luteal cyst or follicle
o Nephrolithiasis
o UTI
-Treatment Approaches
The management of ectopic pregnancy depends on whether the patient is at low or medium risk of tubal rupture. In the presence of rupture, treatment depends on the hemodynamic stability of the patient.
Expectant management
appropriate for the low risk, hemodynamically stable, asymptomatic patient (or with minimal pain), where there is objective evidence of resolution – usually demonstrated by a plateau or decrease in human chorionic gonadotropin (hCG) levels. Patients usually will have spontaneous resolution, with a lower rate expected with higher hCG levels.
Failed expectant management is followed by medical or surgical treatment. Expectant management should be ceased if the patient has increasing pain, hCG levels are not decreasing, or there are signs of tubal rupture.
Medical therapy
Methotrexate is a folic acid antagonist that disrupts rapidly dividing trophoblastic cells. Medical management with methotrexate is reserved for hemodynamically stable patients who have a confirmed or high clinical suspicion of ectopic pregnancy, an unruptured mass, and no absolute contraindications to methotrexate.
• Initial hCG level
It has been suggested that initial serum hCG levels >5000 mIU/mL are predictive of an increased failure rate for medical management, particularly for single-dose regimens, the American Society of Reproductive Medicine states that high initial hCG concentration is a relative contraindication for methotrexate therapy.
• Size of ectopic mass
Ectopic pregnancy size >4 cm is also considered a relative contraindication for medical management, but tubal rupture is unlikely if ectopic size is <2 cm and hCG level is <1855 mIU/mL.
Certain conditions preclude a patient from undergoing treatment with methotrexate, including evidence of immunodeficiency, liver disease (with transaminases more than double normal), renal disease (creatinine >1.5 mg/dL), active peptic ulcer disease, significant pulmonary disease, or hematologic abnormalities (e.g., significant anemia, thrombocytopenia, or leukopenia).
Other contraindications include intrauterine pregnancy, breast-feeding, sensitivity to methotrexate, and the inability to participate in follow-up.
Protocols for methotrexate therapy include single-dose, two-dose, and fixed multiple-dose regimens. The American College of Obstetricians and Gynecologists advise that the single-dose regimen may be an appropriate choice for patients with low initial hCG or plateauing values, and the two-dose regimen an alternative which may be particularly suitable for patients with an initial high hCG.
Once methotrexate has been administered, hCG levels should be serially monitored to asses response until they are undetectable. which usually takes 2 to 4 weeks but can be up to 8 weeks. Further doses of methotrexate may be required depending on the regimen and response to treatment; At any given point in time, if the patient becomes clinically unstable, surgical intervention is indicated.
During methotrexate treatment, vigorous activity and sexual intercourse should be avoided as this may potentially cause a rupture of ectopic pregnancy; pelvic and ultrasound scans should be limited; and patients should avoid folic acid and nonsteroidal anti-inflammatory drugs as these reduce the efficacy of methotrexate. Gas-forming foods should also be avoided as they may produce pain that can be confused with symptoms of rupture. Sunlight exposure may risk methotrexate dermatitis.
Surgical therapy
In patients who are clinically stable with a non-ruptured ectopic pregnancy, laparoscopic surgery and medical management are both reasonable management options and the decision should be guided by initial investigations and discussion with the patient. If a patient shows signs of hemodynamic instability, symptoms of a ruptured ectopic mass, or signs of intraperitoneal bleeding then surgical intervention is required. It is also necessary if the patient has absolute contraindications to medical therapy.
The preferred method is laparoscopy with either salpingostomy or salpingectomy, depending on the status of the contralateral tube and the desire for future fertility.
Hemodynamic instability associated with a ruptured ectopic pregnancy results from severe hypovolemia secondary to blood loss. As such, the management of these patients involves stabilization with emergency fluid resuscitation and immediate transfer to the operating suite. Rapid volume repletion with isotonic solution and blood products is of paramount importance to avoid ischemic injury and multiorgan damage.
Although laparoscopy is the standard surgical approach for the treatment of an ectopic pregnancy in a hemodynamically stable patient (even in the presence of hemoperitoneum), in hemodynamically unstable patients the type of surgery used depends on the experience and judgment of the surgeon and is decided on in consultation with the anesthesiologist. It is not unreasonable to undertake a laparotomy based on the availability of resources (including adequately trained personnel), with the specific procedure dependent on the location of the bleeding.
Rhesus-negative women
The American College of Emergency Physicians' Clinical Subcommittee review found insufficient evidence either for or against treatment with Rho(D) immune globulin in rhesus-negative women with ectopic pregnancy. However, the UK National Institute for Health and Care Excellence (NICE) recommends Rho(D) immune globulin for all rhesus-negative women undergoing surgery for ectopic pregnancy, but not for those treated medically.
Complications
High likelihood of recurrent ectopic pregnancy. Low likelihood of adverse effects of methotrexate therapy such as hepatotoxicity, ulcerative stomatitis, leukopenia thus predisposition to infection, nausea, abdominal pain, fatigue, fever, and dizziness. Also persistent trophoblast, and damage to surrounding organs or vasculature resulting from surgical intervention.