A Tricky Case Of Ectopic Pregnancy 

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📝 ALWAYS FOLLOW THE SCIENCE 📝
.       And When In Doubt; Explore! By Dr Chibuike Joseph Chukwudum

Every illness has a “natural history,” the course it takes, if uninterrupted, to get to the end point. Most times the key to unraveling a case is dependent on the chronological sequence in which the symptoms evolved, and not necessarily on the final picture. 
Thus, while 2 patients may present, for instance, with the same final picture of say cough and breathlessness, the one who developed a productive cough eons before the onset of breathlessness, is more likely to have a respiratory problem; while the one who developed breathlessness first [which progressed from being present only during physical exertion initially, to being present even at rest], and then cough later, is more likely to have a cardiac problem. The same final picture, different diagnoses.
Every illness, in the course of its evolution, leaves vital pieces of clues/evidence in its wake. In clinical medicine, we are taught the “forensics” of digging deep, beneath the surface, to unearth  these pieces of evidence in order to be able to identify the culprit. And when we do, the laboratory is there to uphold,or — as the case maybe– refute the diagnosis; the laboratory is the “litmus test” of the diagnostic process. It has the final say.
Most often than not, the laboratory upholds the diagnosis made clinically, or one of the proposed alternatives [ differentials]. Sometimes, it doesn’t; it instead makes a diagnosis totally different from what was expected. At such times, the said diagnosis must still fit into the clinical picture; that is, it must still be able to explain at least 70% of the patient’s symptoms. If not, the clinician may refuse to work with it, for the cause of the greater good. 
The moto is, “always follow the science.’ And anything that doesn’t conform with the science, must be thrown away.
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📝 THE PRESENTATION
This 30 year old woman walked into the clinic, bending over, and crouching her tummy in pain, as she walked. 
That posture, when seen by a clinician, on its own speaks volumes. And it is neither “merry Christmas,” nor “happy new year” that is says; but something that eloquently expresses the trappings of an “odoriferous saga cum gargantuan gaga,” in Obahaigbonese. If you get what I mean.
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The lower abdominal pain was said to have started some 1 month prior, was particularly worse on the left hand side, and had progressively increased in intensity, becoming more excruciating as the time went by.
About 3 weeks after the onset of the abdominal pain, she developed per vaginal bleeding, which had dragged on for 10 days before she came to the hospital. As expected, she had been binging of herbal concoctions, trying to treat what she thought was an “infection.”
When I examined, and palpated what seemed like a mass at the left side of her lower tummy, I was thinking seriously of a an ectopic pregnancy– a situation in which a baby leaves the womb and starts growing elsewhere instead. For example, inside the Fallopian tubes.
 So, when she said that she hadn’t seen her period in 3 months, I thought I had it right.
But I was to be shocked.

📝 DIGGING UP SIGNIFICANT ANTECEDENTS
She was a grand multiparous woman with 6 kids: 3 boys and 3 girls. What else can an African woman ask of, right? 
So, having completed her desired family size, she had gone for family planning and  had gotten a Jadelle implant, a potent contraceptive.
After the implant, she started having erratic cycles, missing her period for as long as 1 to 3 months some times; so when she missed her period for 3 months, this time around, she thought it was the same thing happening.
While that sounded plausible, I wasn’t taken by it, as her normal menstrual flow usually lasted approximately 4 days; but this one had dragged on for 10 good days!More so, it was associated with abdominal pains out of proportion with the norm.
Also, having had an incident of chronic PID in the past, and two abdominal surgeries, she had an enormous risk of having an ectopic pregnancy. So, I still went ahead and made a diagnosis of ectopic pregnancy.
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📝 CONFLICTING LAB RESULTS
No matter how good one’s “hunches” are, a diagnosis should be confirmed with lab investigations, if time allows for it; and especially where the treatment of such a diagnosis involves an invasive procedure like an abdominal surgery.
So, I sent her for an ultrasound scan and a pregnancy test [PT], in order to confirm the diagnosis.
Due to logistic reasons, the PT was delayed. When the ultrasound result came out, it didn’t show any gestational sac, nor any mass in the tubes. It suggested a diagnosis of chronic PID with post op adhesions.
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📝 FOLLOWING THE SCIENCE
I wasn’t comfortable with that diagnosis. I mean, here’s a woman who;
  – has been having severe lower abdominal pain after 3 months of amenorrhea [cessation of menses].
  – even though she had a contraceptive implant that could explain the amenorrhea, [she] has had per vaginal bleeding for 10 days, as opposed to her normal menses of 3 to 5 days.
  – has a palpable mass at the left iliac fossa, and yet ultrasound couldn’t see any mass in the tube!
  – has significant risk factors for ectopic pregnancy: a previous incident of chronic PID and two previous abdominal surgeries.
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So, I decided to go ahead and explore. Better to open the abdomen and find nothing, than to be sitting around counting pebbles while she ruptures and bleeds to death. 
We had already counselled her, obtained informed consent, and was getting the theatre ready, when the lab resource person came back from the market with PT strips. And alas, it tested positive.
So, if she was pregnant, where then was the baby if the scan could not find “any gestational sac or tubal mass” ?
Could it be that she had an incomplete miscarriage, explaining why the scan didn’t pick anything? Possible; but then the cervical os  was closed [in incomplete miscarriage it is meant to be open], and there was still that abdominal mass that was yet unaccounted for.
So, exploration it is.
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📝 EXPLORATION
When we went in, it was a mess in there. There was a huge mass in the left tube that had ruptured with clots adherent to it.
The fetus, embryo rather; was right there inside the ruptured tube, inside its sac.
We were able to arrest the bleeding, and remove the whole of the left tube, and the gestational sac, en masse [salpnigectomy].
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When the anaesthesia wore off, and she opened her eyes, and was in perfect condition, I was so happy  I took that bold step, despite the conflicting lab results…
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Dante (1) 
 VS
 Grim reaper (0)
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Hoo-Ya! 😜
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🔕 PS
This article does not aim to “vilify” any profession. The result of any scan is as good as the skill of THE PARTICULAR sonographer who did the scan, and not the collective know-how of his profession; just as a doctor’s diagnosis is as good as HIS OWN clinical acumen, and does not reflect that of all the doctors in that country.
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NB: Images are from the net

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