Suspicion and strong instinctive clinical suspicion is the key to diagnosis of ectopic pregnancy. Its usually a combined effort of obstetrician and radiologist, which usually pinpoints the diagnosis. Serum B-HCG markers, which were introduced in early 1980s, can solve this dilemma much easily in almost all instances. However, for some reasons, confusion and lack of emergent management still persists in clinical practice. Few instances I have personally come across -
Case 1:
26 yr old 2 months pregnant female walks into emergency department in night with P/V bleeding. Emergency call was made to sonologist, who found a tiny gestation sac, and a luteal cyst, with no subchorionic collection or sac separation. Case was closed as early pregnancy, and patient was sent home. Patient returns back same very morning, almost fainting, pale in look, hypotensive on examination. Repeat ultrasound was done, which shows similar findings, with an irregular adnexal cystic lesion (discarded as luteal cyst in night) and dirty free fluid in pelvis. He pens down it as possible ruptured ectopic pregnancy, and reviews the gestation sac as 'pseudo-gestational sac'. Obstetrician sees the contradictory reports and does not believe the radiologist. She orders B-HCG, and here was committed a 'sheer crime'. Patient is deteriorating and B-HCG marker is taking its own time. Finally, the verdict comes, with B-HCG of 2500. Patient undergoes laparoscopy, and an ominous ruptured tube is staring at the surgeon, with blood almost in every pocket of abdomen.
Lessons
29 year old female was not getting periods since last one year and was diagnosed with polycystic ovaries 6 months back, for which she is on weight-loss schedule. This time it had been 3 months since she got period. She got her urine pregnancy test done twice in last 2 months, and one two days back, all of them came negative. Gynecologist refers her to evaluate for PCOD. Radiologist saw thick endometrium, tiny follicles in ovaries, and some dirty fluid in pelvis. Just before finishing the examination and labelling it as classical PCOD, he was not sure what to say about this dirty fluid. There was no endometriotic cyst, he was having another cursory look, till he sees some weird soft tissue in left adnexa. He puts on doppler, which shows some vague color flow. Patient was not having any probe tenderness. This is what his report said,
"Heterogenous adnexal soft tissue lesion on left side and fluid with coarse internal echoes in pelvis - Possibilities include ectopic pregnancy, endometriosis or tubal inflammatory etiology. To be correlated with Serum B-HCG and MRI if needed."
Patient got her B-HCG done, and radiologist advised to just delay the MRI till B-HCG report comes. B-HCG came out to be 757 (?). Where do we stand now? Obstetrician felt like she is 'sitting on a bomb' and didn't want to wait for it to explode. She operated it immediately, and saw fiery red fallopian tube, with fimbrial abortion as she could see products of conception floating in pool of blood in pelvis. Rupture could be however avoided or rather contained.
Lessons
27 year old female visits to get an early pregnancy (1st trimester scan), and she had been having spotting since last 2 days. Its already 6 weeks, and radiologist is searching everywhere for the sac, and he sees mildly thick endometrium and thats it! No sac could be seen anywhere. Patient is wincing while the TVS probe is being rotated, not allowing to explore. Well, some pain is expected sometimes in TVS. Radiologist withdraws the probe, however he has limited explanation. He pens down something like this-
"Possibility of recent abortion, very early intrauterine pregnancy, and occult ectopic pregnancy - to be correlated with B-HCG". While patient is better, and gynecologist sends her home. B-HCG comes a magnanimous 10000 IU (!).
Obstetrician feels something fishy, may be she aborted, as we don't see a sac anywhere, and she goes to sleep. She doesn't know, she is 'sleeping on the bomb'. Bomb explodes the next morning, when a collapsed patient is being strolled down on a wheel-chair. And, she commits another crime, when she waits for another scan by a radiologist. Well, he does it and sees blood in pelvis, abdomen, everywhere...declares it as 'ruptured ectopic pregnancy'. Patient gets operated, a mass was also found somewhere in adnexa probably.
Lessons
Case 1:
26 yr old 2 months pregnant female walks into emergency department in night with P/V bleeding. Emergency call was made to sonologist, who found a tiny gestation sac, and a luteal cyst, with no subchorionic collection or sac separation. Case was closed as early pregnancy, and patient was sent home. Patient returns back same very morning, almost fainting, pale in look, hypotensive on examination. Repeat ultrasound was done, which shows similar findings, with an irregular adnexal cystic lesion (discarded as luteal cyst in night) and dirty free fluid in pelvis. He pens down it as possible ruptured ectopic pregnancy, and reviews the gestation sac as 'pseudo-gestational sac'. Obstetrician sees the contradictory reports and does not believe the radiologist. She orders B-HCG, and here was committed a 'sheer crime'. Patient is deteriorating and B-HCG marker is taking its own time. Finally, the verdict comes, with B-HCG of 2500. Patient undergoes laparoscopy, and an ominous ruptured tube is staring at the surgeon, with blood almost in every pocket of abdomen.
Lessons
- for radiologist - till you see a fetal pole, consider possibility of pseudogestation sac and always correlate with B-HCG. Also, have a close look at the luteal cyst, sometimes 'tubal ring' with 'ring of fire' can be seen.
- for obstetrician - always be suspicious of ectopic pregnancy, and never wait for too many reports if you think it is clinically ectopic. You can always close the laparoscopy wound, but avoid a rupture. One clue can create a suspicion, second can make you sure, don't wait for third one!
29 year old female was not getting periods since last one year and was diagnosed with polycystic ovaries 6 months back, for which she is on weight-loss schedule. This time it had been 3 months since she got period. She got her urine pregnancy test done twice in last 2 months, and one two days back, all of them came negative. Gynecologist refers her to evaluate for PCOD. Radiologist saw thick endometrium, tiny follicles in ovaries, and some dirty fluid in pelvis. Just before finishing the examination and labelling it as classical PCOD, he was not sure what to say about this dirty fluid. There was no endometriotic cyst, he was having another cursory look, till he sees some weird soft tissue in left adnexa. He puts on doppler, which shows some vague color flow. Patient was not having any probe tenderness. This is what his report said,
"Heterogenous adnexal soft tissue lesion on left side and fluid with coarse internal echoes in pelvis - Possibilities include ectopic pregnancy, endometriosis or tubal inflammatory etiology. To be correlated with Serum B-HCG and MRI if needed."
Patient got her B-HCG done, and radiologist advised to just delay the MRI till B-HCG report comes. B-HCG came out to be 757 (?). Where do we stand now? Obstetrician felt like she is 'sitting on a bomb' and didn't want to wait for it to explode. She operated it immediately, and saw fiery red fallopian tube, with fimbrial abortion as she could see products of conception floating in pool of blood in pelvis. Rupture could be however avoided or rather contained.
Lessons
- for radiologist- suspicion of ectopic is almost always there! Just have a close look, may be some clue is lying somewhere, while you are rotating your torch (TVS probe) in dark woods.
- for gynecologist - Collect the clues, act at your instinct and at the earliest.
27 year old female visits to get an early pregnancy (1st trimester scan), and she had been having spotting since last 2 days. Its already 6 weeks, and radiologist is searching everywhere for the sac, and he sees mildly thick endometrium and thats it! No sac could be seen anywhere. Patient is wincing while the TVS probe is being rotated, not allowing to explore. Well, some pain is expected sometimes in TVS. Radiologist withdraws the probe, however he has limited explanation. He pens down something like this-
"Possibility of recent abortion, very early intrauterine pregnancy, and occult ectopic pregnancy - to be correlated with B-HCG". While patient is better, and gynecologist sends her home. B-HCG comes a magnanimous 10000 IU (!).
Obstetrician feels something fishy, may be she aborted, as we don't see a sac anywhere, and she goes to sleep. She doesn't know, she is 'sleeping on the bomb'. Bomb explodes the next morning, when a collapsed patient is being strolled down on a wheel-chair. And, she commits another crime, when she waits for another scan by a radiologist. Well, he does it and sees blood in pelvis, abdomen, everywhere...declares it as 'ruptured ectopic pregnancy'. Patient gets operated, a mass was also found somewhere in adnexa probably.
Lessons
- for radiologist - if patient is having pain, you may choose to withdraw the probe, however, convey a strong suspicion of ectopic in view of tenderness.
- for gynecologist - Don't wait till you pile up 'n' number of clues! Stick to the definition, "B-HCG >1000/1500, and no intrauterine gestation sac, thats it, that's what we call ectopic". Never sleep on this report.
