Atypical ectopic pregnancy

Atypical Ectopic Pregnancy THEODORE

Most emergency physicians will agree that bleeding and abdominal pain in women of child-bearing age is considered an ectopic pregnancy until proven otherwise. Ectopic pregnancy remains the leading cause of maternal mortality in the Unlted States. A high index of suspicion is necessary for early intenrentron and reduction in morbidity and mortality. Risk factors for ectopic pregnancy include previous salpingo-oophoritis, ectopic pregnancy, tubal surgery or ligation, use of an intrauterine device, hormonal therapy, and, more recently, in vitro fertilization. In addition, this case emphasizes the possibility of ectopic pregnancy in women with a history of hysterectomy without bilateral oophorectomy. (Am J Emerg Med lgg3;11:233-234. Copyright 0 1993 by W.B. Saunders Company)

CASE REPORT A 34-year-old Hispanic woman with no medical history, gravida 2 para 2002, s/p total abdominal hysterectomy (TAH) presented to our emergency department with the chief complaint of right upper quadrant abdominal pain. The patient was in her usual state of good health until 4 hours before admission when she developed an acute onset of right upper quadrant pain. The patient stated that the pain was of sudden onset, severe intensity, and sharp in quality. The pain was constant and radiated to her right shoulder. The patient denied any palliating or precipitating factors. The pain was associated with nausea and several episodes of bilious vomiting. She denied fever, chills, constipation, diarrhea, dysuria, or vaginal discharge/ bleeding. The patient denied food intolerance or the relationship of pain to meals. The patient’s surgical history was significant for a total abdominal hysterectomy performed for menometorrhagia secondary to fibroid uterus 2 months before admission. At that time, the operative pathology examination disclosed an intact cervix and uterus with leiomyomata, and a small portion of the right fallopian tube. Microscopic examination showed a late secretory endometrium and chronic cervicitis. No other surgical history was elicited. Review of the previous admission stated that her last menstrual period was approximately 4 weeks before surgery. The preoperative serum b-HCG was negative at that time. The patient reports using barrier contraception regularly. She denied any history of using oral contraception or hormonal therapy. The patient denied previous ectopic pregnancy or use of an intrauterine device. The physical examination showed a 34-year-old Hispanic woman, alert and oriented in moderate distress secondary to abdominal pain. Vital statisttcs were blood pressure, 90/60 mm Hg; pulse rate, 92 beats/mitt, respiratory rate 20 breaths/mitt, and temperature, 97°F. Orthostatic changes were noted. Her chest was clear to auscultation and percussion. Heart rate and rhythm were regular with no murmurs, rubs, or gallops. The abdominal examination was significant for a soft, nondistended abdomen with a healed Pfannenstiel inci-

From the Department of Emergency Medicine, Lincoln Hospital and Mental Health Center, Bronx, NY. Manuscript received May 18, 1992; revision accepted November 20, 1992. Address reprint requests to Dr Gaeta, 234 E 149 St, Bronx, NY 10451. Key Words: Ectopic, hysterectomy, pregnancy. Copyright 0 1993 by W.B. Saunders Company 0735-6757/93/l 103-0010$5.00/0

J. GAETA, DO, MICHAEL RADEOS, MD, ILEANA IZQUIERDO

sional scar. Bowel sounds were diminished. There was diffuse abdominal tenderness, markedly increased in the right upper and lower quadrants. No rebound tenderness or rigidity was noted. The pelvic examination showed an intact vaginal cuff. No bleeding or fluctuante was noted at the suture line. A 10 x 8 cm suprapubic mass was palpated in bimanual examination. The rectal examination was unremarkable. Two large bore intravenous lines were placed. The patient was given a fluid challenge with 1 L of lactated Ringer’s solution. Repeat vital signs showed an improved blood pressure, 110/70 mm Hg; pulse rate, 90 beatslmin, and respiratory rate, 16 breaths/mitt. Subjective and objective orthostatic changes had resolved. Routine laboratory tests were sent, and the patient was typed and crossmatched for 6 U of packed red blood cells (PRBCs). Laboratory data showed white blood cell count, 20.4/mm3; hemoglobin, 10.4 g/dL; hematocrit, 31%; platelets, 266,000/mm3; sodium, 139 mEq/dL; potassium, 3.9 mEq/dL; chloride, 102 mEq/dL; bicarbonate, 23 mEq/dL; glucose, 112 mg/dL; blood urea nitrogen, 11 mg/dL; creatinine, 0.9 mg/dL; amylase, 106 IU; SGOT, 13 mg/dL. Urinalysis showed a pH of 5, and a specific gravity of 1.024 with no glucose, protein, bacteria, or occult blood but trace ketones. Microscopic exam demonstrated no RBCs and two to three WBCs. Chest x-ray and obstruction series were unremarkable. A qualitative serum b-HCG was positive. The pelvic ultrasound demonstrated a live fetus approximately 14 weeks by biparietal diameter (BPD). Fetal heart activity and movement were noted. The amniotic fluid seemed to be attached to the abdominal wall. The patient was taken to the operating room where a laparotomy was performed. Operative findings included a marked distortion of the pelvis anatomy with an abundance of adhesions. The placenta and fetus were identified in the pelvis, within a cavity suspected to be the left fallopian tube. There was active bleeding from the placenta and hemoperitoneum. The placenta, fetus, and gestational sac were removed. The postoperative course was uneventful. The patient was discharged home on the fifth postoperative day.

DISCUSSION “If one is confronted with a pelvic condition which follows no rules and conforms to no standards, one should think of ectopic pregnancy . . .“l Ectopic pregnancy, “the great masquerader,” can mimic many other abdominal and pelvic problems. Early diagnosis depends on the clinical caveat, “think ectopic.“* In all women between menarche and menopause who complain of abdominal pain, the possibility of ectopic pregnancy should be considered. The classic triad of pelvic pain, amenorrhea, and an adnexal mass supports the diagnosis; however, women presenting to the emergency department may not have all of these findings. A high index of suspicion, as well as modern diagnostic modalities, can identify ectopic pregnancy and prevent potentially fatal delays in patient management. The incidence of ectopic pregnancy is increasing in the United States, Canada, and Europe by 8% to 16% per year.3 Many studies have listed the generally accepted reasons for 233

234

AMERICAN JOURNAL OF EMERGENCY MEDICINE ??Volume 11, Number 3 ??May 1993

the increasing incidence of ectopic pregnancies.4 Common risk factors for ectopic pregnancy include a history of salpingo-oophoritis, ectopic pregnancy, pelvic surgery, tubal surgery and/or ligation. The use of an intrauterine device, hormonal therapy, and in vitro fertilization are also predisposing factors.’ Our case is presented to remind emergency department physicians that a history of hysterectomy without bilateral oophorectomy does not rule out the possibility of ectopic pregnancy. Ectopic pregnancy after hysterectomy may occur following incomplete surgical procedures (ie, supracervical or subtotal hysterectomy), if the fertilized ovum is in the fallopian tube at the time of surgery, or if a fistulous tract exists between the vagina and the ovaries, enabling fertilization.6 Excluding incomplete surgical procedures, pregnancy after total hysterectomy can be divided into two categories, early ectopic and late ectopic pregnancy. As in our case, the majority of reported cases are early ectopic pregnancies, a function of inadequate preoperative contraception and inability to diagnose early pregnancy at the time of surgery.’ A survey of recent literature shows 33 cases of ectopic pregnancy following hysterectomy. Twenty-two of 33 cases (67%) were described as early ectopic pregnancies. Fertilization through a vaginal-ovarian fistulous tract is considered a late ectopic pregnancy. Fertilization occurs through a fistula secondary to either granulation tissue or prolapse of a fallopian tube that was incorporated in the surgical scar. Approximately 73% of the cases reported followed vaginal hysterectomies (compared with 50% in the early group). The probability of fistulous formation, therefore, seems greater after vaginal hysterectomy than after abdominal hysterectomy.8 The two most common clinical features on presentation to the emergency department are persistent abdominal pain and pelvic mass. Syncope and hemorrhagic shock may occur and are a result of late diagnosis.’ Gastrointestinal disturbances, such as nausea and vomiting, are common. These cases of

ectopic pregnancy following hysterectomy remain a diagnostic dilemma because of the absence of a history of vaginal bleeding or amenorrhea, and typically a low index of suspicion. lo SUMMARY Although posthysterectomy ectopic pregnancy is uncommon, it is not impossible. The clinician should be aware of the possibility of pregnancy despite the absence of a uterus. A delay in diagnosis and treatment may be catastrophic. The diagnosis should be considered in any women of reproductive age who presents with abdominal pain and/or pelvic mass. Confirmatory serum pregnancy test and ultrasonography should be adjunct to a high index of suspicion. REFERENCES 1. Kelly H: Ectopic pregnancy. In Parson S, Langdon T, (eds): Gynecology, ed 2. Philadelphia, PA, Saunders, 1978 pp 100-l 01 2. Droegemueller W: Ectopic pregnancy. In Danforth D (ed): Obstetrics and Gynecology, ed 4. Philadelphia, PA, Harper & Row, 1982, pp 407-422 3. Greisman B: Ectopic pregnancy in women with previous tubal sterilizations at a Canadian Community Hospital. J Reproduct Med 1991;36(3):206-209 4. Chaukin W: The rise in ectopic pregnancy: Exploration of the possible reasons. Int J Gynecol Obstet 1982;20:341-347 5. Chow W, Daling JR, Cates W, et al: Epidemiology of ectopic pregnancy. Epidemiol Rev 1987;9:70-76 6. Cocks P: Early ectopic pregnancy after vaginal hysterectomv. Br J Obstet Gvnecol 1980:87:363-365 7. Bruder M, Vigilante M: Ectopic pregnancy after total hysterectomy. Obstet Gynecol 1973;41(6):891-893 8. Reese W, et al: Tubal pregnancy after total vaginal hysterectomy. Ann Emerg Med 1989;18:1107-1110 9. McDaniel J, Gullo T: Pregnancies after hysterectomies. J National Med Assoc 1968;60(3):386-372 10. Buchan P: Ectopic pregnancy following total hysterectomy. Br J Clin Pratt 1980;34(7):227-228