A 38-year-old Filipino patient, G3P2+0 presented to the emergency department on the 18th of October 2019 complaining of acute onset of lower abdominal pain associated with a history of amenorrhea for three months. She was unsure of the date of her last menstrual period and had no previous antenatal follow-up. She was medically free and her past obstetric history included a normal uncomplicated vaginal delivery, followed by a cesarean section which was performed four years back. She had no allergies and was not taking any medication or contraception. Upon presentation, she complained of generalized lower abdominal pain which was of sudden onset, continuous, not radiating, and not relieved by oral analgesia. The pain was associated with nausea and symptoms of anemia such as dizziness and shortness of breath, but there was no history of loss of consciousness or gastrointestinal or urinary tract symptoms. There was no history of fever or symptoms suggestive of pelvic inflammatory disease.
Upon clinical examination, the patient looked pale and distressed. Her blood pressure was 90/42 mmHg, with a pulse rate of 110 beats per minute. Her abdomen was generally distended and tender on both superficial and deep palpation, with signs suggestive of peritonitis. The digital vaginal examination was positive for cervical motion tenderness and her BhCG Level measured 113000 IU/ml. The examination was complemented by a bedside pelvic ultrasound, which showed an empty uterine cavity as well as a live fetus floating in a moderate amount of free fluid in its pouch of Douglas (Figur. Her hemoglobin count measured 3.2 g/L, and her total white cell count was 7.5 g/L. Blood grouping and cross-matching of four blood units were immediately sent.
The possibility of a ruptured ectopic pregnancy was explained to the patient, and she consented to an emergency laparotomy with possible salpingectomy. During the laparotomy, a total of 4 liters of intra-abdominal blood was suctioned while blood transfusion was ongoing. A live 13-week fetus was found and removed from the pelvic cavity, and the remains of the ectopic pregnancy (gestational sac and placenta) were found along a ruptured right fallopian tube. The right tube was successfully resected, and the specimen was sent to histopathology. Both the right and left ovaries looked normal. Peritoneal lavage was completed, and a large pelvic drain was inserted. The histopathology report revealed chorionic villi within the lumen of the right tube, which was consistent with tubal ectopic pregnancy.
Intra-operatively, the patient received a total of five units of packed red blood cells plus three units of fresh frozen plasma. She was transferred to the Surgical Intensive Care Unit where she was observed for two days. During her ICU stay, she remained hemodynamically stable. Her oxygen saturation was maintained with a 6L O2 face mask. Her chest was clear with bilateral equal air entry. Her abdomen was soft and lax, and the surgical wound was covered with a dressing. The pelvic drain contained humorous fluid measuring around 450cc and urine output was adequate. The repeated hemoglobin level post-transfusion was 10 g/L, and her white blood cell count was 15 g/L. Electrolytes were balanced and double antibiotic coverage was initiated along with anti-stress medications. On post-op day 3, the patient was transferred back to the Gynecology ward. She was discharged home in stable condition five days after surgery.